}- 44. Candidate - Form 4 Municipal Elections Act, 7996 (Section 88.25) 2o kr2o? Instructions. Box A: Name of Candidate and Office.

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1 .V Ontario Mistry of Municipal Affairs Fancial Statement - Auditor s Report Instructions YYYY MM DD YYYY MM OD Forthecampaignperiodfrom(daycandidatefilednomation) }- 44 to f& LInitial filg reflectg fances to December 31 (or 45 days after a by-election) J Supplementary filg cludg fances after December31 (or 45 days after a by-election) Box A: Name of Candidate and Office Candidates name as shown on the ballot Last Name or Sgle Name ca ji 4I1/( Office for which th candidate sought election Candidate - Form 4 Municipal Elections Act, 7996 (Section 88.25) All candidates must complete Boxes A and B. Candidates who receive contributions or cur expenses must complete Boxes C, D, Schedule 1 and Schedule 2 as appropriate. Candidates who receive contributions or cur expenses excess of 10,000 must also attach an Auditors Report. All surplus funds (after any refund to the candidate or their spouse) shall be paid immediately over to the clerk who is responsible for the conduct of the election. Given Name(s) Ward name or no. (if any) Municipality Spendg Limit - General Spendg Limit - Parties and er Expressions of Appreciation f3iiqs El I did not accept any contributions or cur any expenses. (Complete Boxes A and B only) Box B: Declaration I, &QAA,*AO i I declare that to the best of my knowledge and belief that these fancial statements and attached supportg iedules are true and correct. Signature of Candidate ate (yyyy/mm dd) te Filed (yyyy/mm/dd) Time Filed Inil of nd a or Agent (if filed person) I SignClerk or Designa 2o kr2o? Barb Westlake-Powet, a Commissioner for takg Affidavits and Oaths, Middlesex County, while a deputized Clerk of the Corporation of the City of London 9503P (2018/04) Queen s Prter for Ontario, 2018 Disponibie en francais Page 1 of 8

2 Box C: Statement of Campaign Income and Expenses LOAN Name of Amount borrowed bank or recognized lendg stitution A INCOME of all from Total amount Revenue Sign deposit refund Revenue Schedule from 2) Interest earned Other (provide contributions items 25 or less (from le la ScFedule fundraisg events not deemed a contribution by full campaign bank account details) Total Campaign Income (Do not clude loan) 1) (from Part Ill of Cl EXPENSES (Note: clude the value of contributions Expenses subject to general spendg limit Inventory Schedule Advertisg from 1) Brochures/flyers previous campaign used Signs (cludg sign deposit) Meetgs hosted Office expenses curred of this campaign Phone and/or ternet expenses curred Salaries, benefits, honoraria, professional fees curred Bank charges curred Interest charged Other (provide 1 on full loan details) Total Expenses subject to general spendg limit goods and services) (list details Table 4 of s 7M-t. oo pc) = C2 EXPENSES Expenses subject to spendg limit for parties and other expressions of appreciation Total Expenses subject to spendg limit for parties and other expressions of appreciation = C3 9503P (2018/04) Page 2 of 8

3 Expenses not subject to spendg limits Accountg and audit Cost of fundraisg events/activities (list details Part IV of Schedule 2) Office expenses curred after Phone and/or ternet expenses curred after Salaries, benefits, honoraria, professional fees curred after Bank charges curred after Interest charged on loan after Expenses related to recount Expenses related to controverted election Expenses related to compliance audit Expenses related to candidate s disability (provide full details) Other (provide full details) Total Expenses not subject to spendg limits = Total Campaign Expenses (C2 C3 C4) Box D: Calculation of Surplus or Deficit 7 Excess (deficiency) of come over expenses (Income mus Total Expenses) (Cl C5) Eligible deficit carried forward by the candidate from the last election (applies to 2018 regular election only) Total (Dl 02) = If there is a surplus, deduct any refund of candidate s or spouses contributions to the campaign Surplus (or deficit) for the campaign = Dl D2 D3 If le D3 shows a surplus, the amount must be paid trust, at the time the fancial statements are filed, to the municipal clerk who is responsible for the conduct of the election. 9503P (207 8/04) Page 3 018

4 Schedule I - Contributions Part I Summary of Contributions Contributions Contributions (clude value listed money from candidate and spouse goods and services from candidate and spouse Table 3 and Table 4) Total value of contributions not exceedg 100 per contributor Include ticket revenue, contributions money, goods and services where the total contribution from a contributor is 100 or less (do not clude contributions from candidate or spouse). -f- -I-s Total value of contributions exceedg 100 per contributor (from le list details Table 1 and Table 2) Include ticket revenue, contributions 1 B on page money, goods and services where the total contribution from a contributor exceeds 100 (do not clude contributions from candidate or spouse). 5; Less: Contributions returned or payable to the contributor Contributions paid or payable to the clerk, cludg contributions from anonymous sources exceedg 25 Total Amount of Contributions (record under Income Box C) = IA Part 11 Contributions exceedg 100 per contributor dividuals other than candidate or spouse Table 1: Monetary contributions from dividuals other than candidate or spouse Na me Full Address Date Received Amount Received Amount Returned to Contributor or Paid to Clerk Additional formation is listed on separate supplementary attachment 9503P (2018/04) Page 4 of 8

5 Table 2: Contributions goods or services from dividuals other than candidate or spouse (Note: must also be recorded as Expenses Box C) Name Full Address Description of Goods Date Received Value or Services (yyyy/mm/dd) Additional formation is listed on separate supplementary attachment Total Total for Part II - Contributions exceedg 100 per contributor (Add totals from Table I and Table 2 and record the total Part I - Summary of Contributions) I B Part Ill Contributions from candidate or spouse Table 3: Contributions goods or services Description of Goods or Services Date Received Value (yyyy/mmldd) Additional formation is listed on separate supplementary attachment Total 9503P (2018/04) Page 5 of 8

6 Table 4: Inventory of campaign goods and materials from previous municipal campaign used (Note: value must be recorded as a contribution from the candidate and as an expense) this campaign Description Date Acquired Supplier Quantity Current Market (yyyylmm/dd) Value rs -204cc Additional formation is listed on separate supplementary attachment Total 9503P (2018/04) Page 6 of 8

7 Schedule 2 Fundraisg Events and Activities Fundraisg Event/Activity Complete a separate schedule for each event or activity held Additional schedule(s) attached Description of fundtaisg event/activity Date of event/activity (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) Number of tickets sold Total Part I (2A X 2B) (clude Part I of Schedule 1) x 2A 2B = Part II Other revenue deemed a contribution (e.g. revenue from goods sold excess of fair market value) Provide details Total Part II (clude Part I of Schedule 1) = Part Ill 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 Ill (clude under Income Box C) = Part IV Expenses related to fundraisg event or activity Provide details Total Part IV Expenses (clude under Expenses Box C) = 9503P (2018/04) Page 7 of 8

8 Auditor s Report Municipal Elections Act 1996 (Section 88.25) A candidate who has received contributions or curred expenses excess of 10,000 must attach an auditors report. Professional Designation of Auditor Municipality Date fyyyy/mm/dd) Contact Information Last Name or Sgle Name Given Name(s) Licence Number Address Suite/Unit No. Street No. Street Name Municipality Provce Postal Code Telephone No. (cludg area code) Address The report must be done accordance with generally accepted auditg standards and must: set out the scope of the examation provide an opion as to the completeness and accuracy of the fancial statement and whether it is free of material misstatement Report is attached Personal formation, if any, collected on this form is obtaed under the authority of sections and 95 of the Municipal Elections Act, Under section 88 of the Municipal Elections Act, 7996 (and despite anythg the Municipal Freedom of Information and Protection of PrivacyAct) documents and materials filed with or prepared by the clerk or any other election official under the Municipal Elections Act, 7996 are public records and, their destruction, may be spected by any person at the clerk s office at a time when the office is open. Campaign fancial statements shall also be made available by the clerk an electronic format free of charge upon request. 9503P (2018/04) Page 8 of 8