Financial Statement Auditor s Report

Transcription

1 Coo r r"', nstructons Mnstry of Muncpal Affars Ontaro and Housng All canddates must complete Boxes A, B, C, D, E and F and Schedule Fnancal Statement Audtor s Report Form 4 Muncpal Electons Act, 1996( Secton 78) AU canddates must complete Schedules 2, 3 and 4 as approprate. Canddates who receve contrbutons or ncur expenses n excess of$ 10, 000 must also attach an Audtor' s Report. All surplus funds( after any refund to the canddate or hs or her spouse) shall be pad mmedately over to the clerk who was responsble for the conduct of the electon. YYYY MM DD YYYY MM DD For the campagn perod from( day canddate fled nomnaton) to o s. f' t Prmary flng reflectng fnances to December 31 ( or 45th day after votng day n a by-electon) Supplementary flng ncludng fnances after December 31 ( or 45th day after votng day n a by-electon) Box A: Name of Canddate and Offce Name of Canddate Qua 4 e/ Last Name Name Mddle ntal Malng Address Sute/ Unt No. Street No. Street Name 61,/ Cty/ Town O Provnce tal Code Pf Telephone No.( ncl. area code) Fax No. Emal Address Ceusness Home 0-- d14 Y-,5 35 rzl1d a / rey,dtecd, ( Name of offce for whch the canddate sought electon Ward Name or No.( f y) 4' Name of Muncpalty Box B: Summary of Campagn ncome and Expenses My spendng lmt( as ssued by clerk) was 15'--- Surplus( or defct) from prevous electon 0-4. My total campagn expenses that were subject to the spendng lmt were ( from Box C) $ 5. My total campagn expenses that were not subject to the spendng lmt were ( from Box C) - - $ 0 6. Total of all campagn expenses ( from Box C) 7. Electon campagn surplus/ defct from current electon ( from Box E) 1$ 8. Contrbutons refunded to canddate or spouse ( from Box E) Total contrbutons receved ( from Schedule 1) Amount pad to clerk ( from Box E) r l' 9503P( 2010/01) Queen' s Prnter for Ontaro, 2010 Dsponble en francas Page 1 of 8 r

2 Box1C: Statement of Campagn Perod ncome and Expenses From To For Canddate YYYY MM DD YYYY MM DD a CNCOME Canddate' s surplus from mmedately precedng electon released by the clerk + ' Contrbutons from canddate Contrbutons from spouse of canddate All other contrbutons Revenue from fund- rasng functons not deemed a contrbuton from Schedule 2, Part ll) nterest ncome Other( provde full detals) le ft fjj lnnlle (4' 1 8' Total Campagn Perod ncome 6 C1 EXPENSES( Note: nclude the value of contrbutons of goods and servces) Expenses Subject to Spendng Lmt Advertsng 0 Bank charges e- Brochures 0' nterest on loan 8-. nventory contrbuted to canddate' s campagn( Schedule 3) Meetngs hosted 0' Nomnaton flng fee Offce expenses Phone and/or nternet 41" Salares and benefts/honorara/ professonal fees 6)- Sgns 0- Other( provde full detals) 6'- a. Subtotal C2 Expenses Not Subject to Spendng Lmt 64 Accountng and audt Costs of fund- rasng functon ( from Schedule 2, Part V) 1`/" Expenses related to complance audt Expenses related to controverted electons 6) 6t' Expenses related to recounts Votng day party/ apprecaton notces Expenses related to canddate' s dsablty( provde detals) S 6> Subtotal C3 Total Campagn Perod Expenses( C2)+( C3) C4 Excess( Defcency) of ncome over Expenses( C1)-( C4) tg 9503P( 2010/01) Page 2 of 8

3 . Box D: Statement of Assets and Labltes as at. 20 Assets Cash ' 1$ 1*--- ccounts recevable alue of nventory retaned ( from Schedule 4) 0- Other( provde full detals) Total Assets Labltes and Excess( Defcency) of ncome over Expenses Accounts payable Borrowngs, overdraft Other( provde full detals) 49- Total Labltes Box E: Statement of Determnaton of Surplus or Defct and Dsposton of Surplus Part - Determnaton of Surplus or Defct ry Amount of excess( defcency) of ncome over expenses ( from Box C) El Deduct: Any defct carred forward by the canddate from mmedately precedng electon f the offces are wth respect to the same jursdcton Surplus( or defct) for the campagn perod( El)-( E2) j$ CDeduct: Any refund of contrbutons to the canddate or spouse( only f there s a surplus) Total Determnaton C E3 E2 Part - Dsposton of Surplus f lne E3 shows a surplus, the amount must be pad n trust, at the tme the fnancal statements are fled, to the muncpal clerk who was responsble for the conduct of the electon. Surplus pad to the muncpal clerk of the muncpalty of Box F: Dec, / j Al, _ r ton - / / / a canddate n the muncpalty of fnancal statements and attached supportng schedules are true and correct. hereby declare that to the best of my knowledge and belef that these Declared before( clerk or commssoner) n the on ( yyyy/ mm/dd) a0 À & L/ L3 Sgna ure of Clerk or Commssoner l gnature of Canddate tr ō ( k-( Date Fled n the Clerk's Offce( yyyy/mm/dd) 9503P( 2010/ 01) Page 3 of 8

4 Schedule' 1- Contrbutons Part Contrbuton Contrbuton from canddate Q- Contrbuton from spouse rotal from each sngle contrbutor totallng more than $ 100 nclude all tcket revenue where tcket prce exceeds$ 100 nclude all goods and servces where value exceeds$ 100 do not nclude contrbutons from canddate or spouse Total from each sngle contrbutor totallng$ 100 or less nclude all tcket revenue where tcket prce s$ 100 or less nclude all goods and servces where value s$ 100 or less* do not nclude contrbutons from canddate or spouse Note: Goods and servces must also be reported as expenses n Box C Less: Contrbuton returned or payable to the contrbutor Contrbuton pad or payable to the clerk Total Amount of Contrbuton Total contrbuton from anonymous sources MEM 11A 1B Amount of contrbutons pad or payable to the clerk( 1A)+( 1B) Part Lst of Contrbutons from Each Sngle Contrbutor Totallng More than $ 100 Table 1: Monetary contrbutons from ndvduals other than canddate or spouse Name Address Amount S M Addtonal nformaton s lsted on separate supplementary attachment Total $ 9503P( 2010/01) Page 4 of 8

5 Table 2: Monetary contrbutons from unons or corporatons Name( Legal and Carryng on Address Presdent or Cheque Sgnatory Amount Busness As) Busness Manager f-- Addtonal nformaton s lsted on separate supplementary attachment Total $ cable 3: Contrbutons n goods or servces( Note: must also be reported as expenses n Box C) Name Address Goods or Servces Amount Addtonal nformaton s lsted on separate supplementary attachment Total $ Total Part Contrbutons 9503P( 2010/ 01) Page 5 of 8

6 Schedule - Fund-Rasng Functon Addtonal schedule for each event or actvty held s/ are lsted on separate supplementary attachment( s) Date Descrpton of event or actvty YYYY MM DD C Admsson charge( per person)*( may not exceed ndvdual contrbuton lmt) e 2A f admsson charge per person s not consstent, attach complete breakdown of all tcket sales. Number of tckets sold 2B Part Tcket Revenue Lnes:( 2A) x( 28)( nclude n Schedule 1) L$ Part Other Revenue Deemed A Contrbuton Provde full detals( e.g., revenue from goods sold n excess of far market value) Total Part Revenue( nclude n Schedule 1) Part Other Revenue Not Deemed A Contrbuton Provde full detals( e.g., contrbutons of$ 10 or less; revenue from refreshment sold at cost) Total Part Revenue( nclude n Box C) Part V Venue Expenses Related to Fund-Rasng Functon Event advertsng Food and drnk Entertanment Other( provde full detals) Total Part V Expenses( nclude n Box C) q 9503P( 2010/01) Page 6 of 8

7 CO Schpdute 3- nventory of Campagn Goods and Materals( from Prevous Campagn) f Used n Canddate' s Campagn Descrpton Date Acqured Suppler Unt Value at Quantty Total Value yyyy/ mm/ dd) Tme of Purchase Total Value of nventory from Prevous Campagn Used n Canddate' s Campagn Schedule 4- nventory of Campagn Goods and Materals at The End of Campagn Descrpton Date Acqured Suppler Unt Value at Quantty Total Value yyyy/ mm/dd) Tme of Cy Total Value of nventory of Campagn Goods and Materals 9503P( 2010/01) Page 7 of 8

8 Audtor's Re ort' P Muncpal Electons Act, 1996( Secton 78) A.canddate who has receved contrbutons or ncurred expenses n excess of$ 10, 000 must attach an audtor's report. The report must be done n accordance wth generally accepted audtng standards and must: set out the scope of the examnaton C provde an opnon as to the completeness and accuracy of the fnancal statement and whether t s free of materal msstatement k' Professonal Desgnaton of Audtor Muncpalty Date( yyyy/ mm/ dd) Contact Person Last Name Frst Name Lcence No. Address Sute/ Unt No. Street No. Street Name. Cty/ Town Provnce Postal Code Telephone No.( ncl. area code) Fax No. Emal Address ext. C C 9503P( 2010/ 01) Page 8 of 8