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Home My WebLink AboutAlma Sandoval�r�� r Ontario Ministry of Municipal Affairs Financial Statement - Auditor�S R@�]O�"t and Housing Form 4 Municipal Elections Act, 1996 (Section 78) Instructions: All candidates must complete Boxes A and B. Ca�didates whD receive contributions or incur expenses beyond the nomination fee must complete �oxes C, D, Schedule 1, and Schedule 2 as appropriate. Candidates who receive contri6utions or incur expenses in excess of $10,000 must also attaCh an Auditors Report. All surplus funds (after any refund to the candidate or his or her spouse) shall be paid immediately over to the clerk who was responsible for the conduct bf the election. YYYY MM DD YYYY MM DD For the campaign period from (day candidate filed nomination) '�� r� �e � ! C� to *�(� y�; (j � � 1 ❑ Primary filing reflecting finances to December 31 (or 45"' day after voting day in a by-election) ❑ Supplementary filing including finances after December 31 (or 45ih day after voting day in a by�lection) Box A: Name of Candidate and Office Candidate's name as shown on the ballot Last Name � Given Name(s) /�, g, (`"@: d,j, , ;r i,� ,' , + � � �� '� �d -S � -��1 � "i.�\ _. Name of offce for which the candidate sought Name of Municipality Spending limit issued by clerk � � �i , :� � ; C�,. � � �__ k_ _'�.� �, �� -:'; Ward name or no anV) � I did not accept any contributions or incur any expenses other than the nomination fee. (Complefe Box A and 8 only) Box B: Dedaration � , a candidate in the municipality of ��.. :_.. '°s ��_�-. `� �`� �p , hereby dedare that to the best of my knowledge and belief that these financial statements and attached s�pporting schedules are true and correct. Declared before (clerk or commissioner) � 1� in the � iTc„ C:� �': C. z"_r � Ir� c,� on �YYYY/mmldd) �� C � �� -� . � - r�_�'li-.Z�� Signature of Clerk or Commissioner , � " Signature of Candidate +�-� 0 � / �= ?' �'' �`� Date Filed in the Clerk's Office (yyyy mm/dd) '°�'�""�°°�` °�"�"q DE�L IE M. �F41��i1S. Gt�Y CLERK, � ��IiX O� PI�{��I�C, EX QFFlCIC� �Q�,ii�ViI�SI�NER PUR�l3P�N� TC� 5�1�°�90�° 112) � OF THE C�JMN9BS�lONERS FOFi � TAICIIVG AFFIDAV�T� ACT. k 3503P (2013/'I 1) OO Queen's Pnnter for Ontano, 2013 . Disponible en fran�ais Page 1 of 8 Box G: Statement of Campaign Income and Expenses LOAN ' Name of bank or recognized lending institution Amount borrowed $ lNCOME Totai amount of all contributions (From line 1A in Schedule 1) Refu�d of nomination filing fee Sign deposit refund. Revenue from fund-raising events not deemed a contribuiion (From Part I11 of Schedule 2) lnterest eamed by campaign bank account Other (provide full details) 1. 2. 3. Total Campaign Incame (Do not include loan) EXPENSES (Note:, include the value of contributions of goods and services) Expenses subject to spending limit Nomination filing fee Inventory from previous campaign used in this campaign (list details in Table 5 of Schedule 1) Advertising Brochures/flyers Signs (including sign deposit) Meetings hosted Office expenses incurred until voting day f'hone and/or Internet expenses incurred until voting day Salaries, benefits, honoraria, professional fees incurred untii voting day Bank charges incurred until voti�g day Interest charged on loan until voting day Other (provide full details 1. %i � C �=` .S �-'`�} r �'i,� �� °a'' � 2. 3. Total Expenses subject to spending limit Expenses not subject to spending lirnit Accounting and audit Cost of fund-raising events/activities (list details in Part IV of Schedule 2) Voting day party/appreciation notices Office 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 voti�g day Interest charged on loan after voting day Expenses related to recount Expenses related to controverted election Expenses related to compliance audit Expenses related to candidate's disability (provide full details) 1. 2. 3. Other (provide full detaifs) 1. 2. 3. Tatal Expenses nof subject to spending fimit Total Campaign Expenses {C2 + C3) 9503P (2013/11) + $ + $ + $ + $ + $ + $ + $ + $ _ $ + � I ��.� C1 + $ + $ j �, � � � I.�qie �=��3 = �� 1. � + `�' ��Adab i� + $ + � + �'.��.� � 8 j :3 - �° + $ + $ + $ + $ 6�.�fC>-� �f �� = jG: �� +� + $ _ � � � '�,�� cz + $ + $ + $ + $ + $ + $ + $ + � + $ + $ + $ + $ + $ + $ + $ + $ + $ _ $ C3 _ � C4 Page 2 of 8 B�x D; Calc�alafian of Sur�lus or Deficit Excess (deficiency) of income over expenses (Income — Total Expenses) (C1 — C4) + $ �1 Efigible deficit carried fotward by the candidate from the last election —$ D2 Total (D1 — D2) _ $ If there is a surplus, deduct any refund of candidate's or . spouse's contnbutions to the campaign —$ Surplus (or deficit) for the campaign =� 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 was responsibfe for the conduct of the election. Amount of $ paid to municipal clerk in the municipality of °5o3P (2013t11) Page 3 of 8 Schedule 1 - Contributions Part 1— Summary of Contributions Contribution from candidate (include the value of inventory listed in Tabie 5) +$ Contribufion from spouse • + � Total value of contributions not exceeding $100 per contributor • Inciude 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 or spouse). +� Total value of contributions exceeding $100 per contributor (from line 1 B; list details in Tables 1 —4) • Include ticket revenue, contributions in money, goods and services where the total contribution from a contributor exceeds $100 (do not inciude aontributions from candidate or spouse). +� Less: Contributions retumed or payable to the contributor —� Contributions paid or payable to the derk, including contnbutions from anonymous sources exceeding $10 — $ Total Amount of Contributions (Record in Box C) _� 1A Part II — List of Contributions from Each Single Contributor Totalling more than $100 T�hlp �• ne�nPtarv enntrihuti�ns from individuals other than candidate or spouse 9503P (2013/11) Page 4 of 8 Table 2: RAoneiary contributions from corporations or unions Table 3: Contributions in goods or services from individuals other than candidate or spouse 9503P (2013/� 1) Page 5 of 8 Table 4: Contributions in Name of Corporatian (Legal and Carrying on Business As) goods ar services from corporations or unions (Note: must also be recarded as expenses in Box C} Full Address President or Authorized Description of Value $ Business Manager Representative Goads or Services � Additional infarmation is listed on separate supplementary attachment Total Part II Contributions (Add Totals from Tables 1-4) (Record in Part 1— Summary) ParE 111— Inventory Table 5: Inventory of Campaign Goods and Materials from Previous Campaign used in this Campaign _ " . . . . .. .. � .. i�_ _ _ ___ J.J_L_ __J �� ..� .��......r�.1 Total 1B 8503P (2013/11) Page 6 of 8 Schedu{e 2— Funciraising Events and Activities Fundraisiny Event/Activity Complete a separate scheduBe far each event or aciivity he(d � Additional schedule(s) attached Description of fundraising event/activity Date of evenUactivity (yyyy/mm/dd) _ Part 1— Ticket Revenue Admission charge (per person) (ff there are a range of ticket prices, attach complete breakdown of all ticket sales) + $ Number of tickets "sold X Total Ticket Revenue (2A X 2B) (include in Schedule 1) 2�4 2B _ $ Part 11— Other revenue deemed a contribution (provide details (e.g. revenue from goods sold in excess of fair market value)) 1. 2. 3. 4. 5. Total Part fl Revenue (indude in Schedule 1) + $ + $ + $ + $ + $ Part 111— Other revenue not deemed a contribution (provide details (e.g. contributions of $10 or less; market value of goods or services sold)) 1. + $ 2- + $ 3. + $ 4. + $ 5. + $ Total Part 111 Revenue (include in Box C) Part IV — Expenses related to fundraising event or activity (provide details) 1. 2. 3. - 4. 5. 6. 7. 8. Totaf Part N Expenses (indude in Box C) + $ + $ + $ + $ + $ + $ + $ + $ _ $ _ $ _ $ 35D3P (2013/11) Page 7 of 8 Audito�'s .Report Municipal Electior+s Act, 1996 (Section 78} ; A candidate who has received contributions or incurred expenses in excess of $10,000 must attach an auditor's report. Professiorral Designation of Auditor Contact Information Last Name Addrass � Suite/Unit No. � Street No. � Street Name City/Town Telephone No. (including area code) Fax No. e�. uate �yyyyimm�oa� Licence lvumnei Province � Postal c�ode Email Address The report must be done in accordance with generally accepted auditing standards and must: • set out the scope of tne examination • provide an opinion as to the completeness and accuracy of the financial statement a�d whether it is free of material misstatement ___ � Report is attached Personal informafion, if any, collected on this form is obtained under the authority of sections 78 and 95 of the Municrpal Elections Act, 1996. Under section 88 af the Municipal Elections Act, 1996 (and despite anything in the Municipal Freedom of Information and Protecfion of Privacy Act) documents a�d materials filed with or prepared by the clerk or any other election official under the Municipal Electiorrs Act, 1996 are pubfic records and, until their destruction, may be inspected by any person at the clerk's office at a time when the o�ce is open. Campaign financial statements shall aEso be made availab{e by the clerk in an electronic format free of charge upon request. 3503P (2013/� 1) Page 8 of 8