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1 ~ r~.> ~`" Ontario Ministry of Municipal Affairs Financial Statement -Auditor's Report Candidate -Form 4 _ Municipal Elections Act, 7996 (Section $8.~5) Instructions All candidates must complete Boxes A and B. Candidates who receive contributions or incur expenses must complete Boxes C, D, Schedule 1 and Schedule 2 as appropriate. Candidates who receive contributions or incur expenses in excess of $10,Od~ must also attach an Auditor's Report. _ All surplus funds (after any refund to the candidate or their spouse) shall be paid immediately over to the clerk who is r,~sponsible for the rnnrii ict of tha alar4inn YYYY MM DD YYYY MM DD For the campaign period from (day candidate filed nomination) I ~ ~ ~~ I ~ ~ I ~}~ I t I ~~ 1 ~ I ~~ 13 Initial filing reflecting finances to December 31 (or 45 days after voting day in airy-elution) _ ~--..- ~ Box A: Name of Candidate and Office ~ Candidate's name as shown on the ballot Last Name or Single Name ~ ~~ ~~' ~ /~ Given Names) /,//, ~/I~/~ tjt~ig6 TOf WftlGfl Lfle Gaf1QIQaj6 SOU9(li 61eC[IOfI vvara name or na fir any ST cry ~'ti~~~~~~ pending Limit -General ~ q~ ~~ ~ Spending Limit -Parties and Other Expressions of Ap~iation M unicipality.,~ ~ ~ did not accept any contributions or incur any expenses. (Complete Boxes A and 8 only) > box 6: Declaration!e STS V~ statements and attached supporting schedules a're true and correct. uc~iaic uia~ w uic ucsi ~~ any n~wvvicuyc anu ucuc~ u~ai uicac in~aiwia~.~~.nyu iu~c ~ ~.a~iu~uatc ucric 1YYYY~~~~~~~ ul +, Date. Filed (yyyylmmldd) Tirn~.Filed initial of Gandidat g nt ~i~ filed in pegson) S' r of Clerk or Des' ate?018 o ~z I~ ~ ' 15~.~ 1, i~ f. ~.~ r ~ ~ ~~ /~ ~ C V ~E~ ~ ~ L~ ~ ':,iifc ~',iis ti~o-dul7k, (:t'~r Z92F'K, C13y Qf st. CatFlBfl,I1~S, A ~<',r.,,,;~issio~er ffor t~kina~ arf c r:~ots. Region of Niagara CITY CLEF~eC'S ~FFlCC ~F. ~;a1thar!!~'~5, OIATARlC1 9503P (2018!04) 0 Queen's Printer for Ontario, 2018 Disponible en franpais Page 1 of 8
2 Box C: Statement of Campaign Income and Expenses LOA~I Name of bank or recognized lending institution Amount borrowed..; INCOME Total amount of all contributions (from line 1A in Schedule 1) Revenue from items $25 or less Sign deposit refund Revenue from fundraising events not deemed a contribution (from Part III of Schedule 2) Interest eamea by campaign bank account Other (provide full details) Total Campaign Income (Do not include loan) +~~~ ~m~v + ~ ~v v~.._., + ~ ` r. + ~ ". r ~,,~ ~ EXPENSES (Note: include the value of contributions of goods and services) Expenses subject to general spending limit Inventory from previous campaign used in this campaign (list details in Table 4 of Schedule 1) Advertising Brochures/flyers Signs (including sign deposit} Meetings hosted Office expenses incurred until voting day Phone and/or intemet expenses incurred until voting day Salaries, benefits, honoraria, professional fees incurred until voting day Bank charges incurred until voting day Interest charged on loan until voting day + ~ -r ~' ~ + ~ f' G" ~ "`.~ _ `~~_ 1. t ~.---,,. 2. ~ 4. ~.~~ -~ Total Expenses subject to general spending limit = $ ~) ~! ~~ ~ C2 ~XPENS@S Expenses subject to spending limit for parties and other expressions of appreciation 1. + ~ ~ 4. ~ 5. + ~ ~ Total Expenses subject to spending limit for parties and other expressions u~ apprcciauun - w (;3 9503P (2018/04) Page 2 of S
3 Expenses not subject to spending limits Accounting and audit!~ Cost of fundraising events/activities (list details in Part IV of Schedule 2) ' ditice expenses incurred after voting day Phone and/or intemet expenses incurred after voting day Salaries. benefits. honoraria. professional fees incurred after voting day Bank charges incurred after voting day i Interest charged on loan after voting day ~- Expenses related to recount ~. Expenses related to controverted election ~ Expenses related to compliance audit _ ~...~...~ ~...,., ~ ~.~ ~..~...,..... ~...,..~u. Y 1M......~....w~.+~ 2. ~- $. + ~ ~- 4. ~ S Other (provide full details) 2. * ~ f $ 5. Total Expenses not subject to spending limits = $ ~C4 Total Campaign Expenses (C2 + C3 + C4) ~ - ~ ~/C,z ~ 2~ ~5,~ Box D: Calculation of Surplus or D~cit Excess (deficiency) of income over expenses (Income minus Total Expenses) ~j (~1 ~5~ + ~ `~ Ct ~ D1 Eligible deficit carried forward by the candidate from the last election (applies to 2018 regular election only) $ _i D7 ' Total (D'1 D2) _ $ ~ ~}- ~~(~F' If there is a surplus, deduct any refund of candidate's or!c^~ ~. spouse's contributions to the campaign $ 7 Surplus (or deficit) for the campaign +.~i = ~ D3 If line D3 shows a surplus, the amount must be paid in trust, at the time the financial statements are filed, to the municipal clerk who is responsible for the conduct of the election. 9503P (201 Sl04) Page 3 of S
4 Schedule 1 -Contributions Part 1 Summary of Contributions Contributions in money from candidate and spouse Contributions in goods and services from candidate and spouse (include value listed in Table 3 and Table 4) T otal value of contributions not exceeding $100 per contributor Include ticket revenue, contributions in money, goods and services where the total contribution from a contributor is $100 or less (do not include contributions from candidate ar spouse). Total value of contributions exceeding $100 per contributor (from line 1 B on page 5; II4t fip~aiic in Tahla 1 an~i Tahla 71 Include ticket revenue, contributions in money, goods and services where the total contribution from a contributor exceeds $100 (do not include contributions from candidate or spouse). + ~ ~, 3~C~~(~:1 + ~ ~~ ~ /UQJ. ~ ~(Y~ Less: Contributions returned or oavable to the contributor $ Contributions paid or payable to the clerk, including contributions from anonymous sources exceeding $25 $ Total Amount of Contributions (record under Income in Box C) _ ~ (J~ 1A Part II Contributions exceeding X100 per contributor individuals other than candidate or'spouse Table 1: Monetary contributions from individuals other than candidate or spouse Name Full Address Date Received Amount Received $ i~j~(,,li~~`~t. ~~.IGC ~~ ft~~~ ~-ZM ~,~ ~ ~f/~~ l ~~ c~ ~(J ~~ ~ ~~ ~~ ~ ~ ~ ~ ~r~i'r~ ~ ( lc ~(~ L2~ ~~ G l ~~ Amount $ Returned.to Contributor or Paid to Clerk _ ~...,~ Additional information is listed on separate supplementary attachment Total 9503P (2018/04) Paga 4 of 8
5 Table 2: Contributions in goods or services from individuals other than candidate or spouse (Note: must also be recorded as Expenses in Box C) Name Full Address Description of Goods or Services Date Received (yyyy/mm/dd) Value,$' i' r" ~,. ' r d Additional information is.listed on separate supplementary attachment Total Total for Part II -Contributions exceeding $100 per contributor (Add totals from Table 1 and Table 2 and record the total in Part 1 -Summary of Contributions),. Part 111 Contributions from candidate or spouse $ 1B Table 3: Contributions in goods or services Description of Goods or Services Date Received Value $ (yyyy/mm/dd).~.~ f,. :~,/ r s /, ~` 9503P (2018/04) Page 5 of 8
6 Schedule 2 Fundraising Events and Activities Fundraising EvenUActivity Complete a separate schedule for each event or activity held Additional schedules) attached Description of fundraising evenuactivity Date of evenuactivity (yyyy/mm/dd) Part I Ticket revenue Admission charge (per person) (If there are a range of ticket prices, attach complete breakdown of all ticket sales) $ Zq Number of tickets sold X zb Total Part I (2A X 26) (include in Part 1 of Schedule 1) _ $ Part II Other revenue deemed a contribution (e.g. revenue from goods sold in excess of fair market value) Provide details ~ Total Part II (include in Part 1 of Schedule 1 ~ _ $ Part III Other revenue not deemed a contribution (e.g. contribution of $25 or less; goods or services sold for $25 or less) Provide details Total Part 111 (include under Income in Box C) _ $ Part IV Expenses related to fundraising event or activity Provide details q ~ 6. + ~ ~. 8. Total Part IV Expenses (include under Expenses in Box C) _ $ + ~ 9503P (2018/04) Page 7 of 8
Financial Statement - Auditor's Report Candidate - Form 4
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