HomeMy WebLinkAboutAnita Ottor�� .
�r" �ntario Ministry of Municipal Affairs Financial Statement — Auditor's Report
and Housing
rorm 4
Municipal Elections Act, 1996 (Section 78)
Instructions:
All candidates must complete Boxes A and B. Candidates who receive contributions or incur expenses beyond the nomination fee
must complete Boxes C, D, Schedule 1, and Schedule 2 as appropriate. Candidates who receive contributions or incur expenses in
�xcess o€ $1 �,000 rnus4 also atiaci� an Auditor's Repoit.
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 of the election.
YYYY MM DD YYYY MM DD
� � � � �
For the campaign period from (day candidate filed nomination) � �'�� � `� � � � ���f � to �'�� � � � �-� 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 45�h day after voting day in a by-election)
Box A: Name of Candidate and Office
Candidate's name as shown on the ballot
Last Name
�.9ii0
Given Name(s)
<'�i:�;ii.
Name of office for which the candidate sought election Ward name or no. (if any)
;
q y, �`s � >�s;���:�ri � 't�v:a�., ,
Name of Municipality
[��!i��e�?a�?
Spending limit issued by clerk
$� �'�.�'?�'.9d?
❑ I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and 8 only)
Box B: Declaration
I, ,',�?iF;; �!iF:�}
, a candidate in the municipality of
��!��E�!i;is� � , hereby declare that to the best of my knowledge and belief that these
financial statements and attached supporting schedules are true and correct.
Declared before (clerk or commissioner)
i n the � ��t/� Cj"F �� C,1/ C,i�-� �4
on IYYYY/mmiad) o�� 1(q ( a3 %��-f .
O�"�G%l'�i���/�l�/
Signature of Clerk or Commissioner
aa��ic����a�
Date Fileci in the Clerk's Office (yyyy/mm/dd)
?..E��a �9�tAl�f� &��4����
a ��;rcmissi�re�� et�;.,��gioTallVlunicipalitV
04 �Farham, fos ihe Corpera4ion ofthe
�rty0f �'ICkQPIit�.
Ex�;ires January 2g, 2018.
%
Signature of Candidate
�
9503P (2013/11) OO Queen's Printer for Ontario, 2013 Disponible en fran�ais Page 1 of 8
Box C: Statement of Campaign Income and Expenses
LOAN
Name of bank or recognized lending institution tr
Amount borrowed - - - - - - - - + $ yi.���r
INCOME
Totai amount of all contributions (From line 1A in Schedule 1) +
Refund of nomination filing fee +
Sign deposit refund +
Revenue from fund-raising events not deemed a contribution (From Part III of
Schedule 2) +
Interest earned by campaign bank account +
Other (provide full details)
1. +
2. +
3. +
Total Campaign Income (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
ofSchedule 1) +
Advertising +
Brochures/flyers +
Signs (including sign deposit) +
Meetings hosted +
Office expenses incurred until voting day +
Phone and/or Internet 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 +
Other (provide full details)
1. � ,°�,_;�� 3_�=e�° V.��€ � ,,�.:��; +
2 +
3. +
Total Expenses subject to spending limit =
Expenses not subject to spending limit
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 Internet expenses incurred after voting day +
Salaries, benefits, honoraria, professional fees incurred after voting day +
Bank charges incurred after voting 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 details)
1. +
2. +
3. +
Total Expenses not subject to spending limit
Total Campaign Expenses (C2 + C3)
$ j.000.00
$ 0.00
� 0.00
$ 0.00
$ �,4?(�
$
$
$
$ �6,�(9(���'� C1
� 1 Gr).�)';�
$ 0.00
$ 30.00
� 875.75
$ ?��%5.75
$ 0.00
$ 0.00
$ 0.00
� 133.94
� 4.??
$ i�.d)�?
$ I % I .�=�
$ � � � �)0.9Q C2
$ 0.��()
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 9.10
$ 0.00
$ �).00
$ n.QO
$ y9.?,�s;!
$
$
$
$
$
$
_ $ �r�. � �} C3
_ $ ?. '��Se.")�) C4
9503P (2013/11) Page 2 of 8
Box D: Calculation of Surplus or Deficit
Excess (deficiency) of income over expenses (Income — Total Expenses)
(C1 — C4)
Eligible deficit carried forward by the candidate from the last election
Total (D1 — D2)
If there is a surplus, deduct any refund of candidate's or
spouse's contributions to the campaign
Surplus (or deficit) for the campaign
+ $ ;�)O.U(� D1
- $ 0.0(� D2
_ $
— $ ! �'; E.Y'i. . ; � i
_ � t�.(}�� 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
responsible for the conduct of the election.
Amount ofi $Z� ��`�'��� paid to municipal clerk in the municipality of °- s�e�' ���� a'' ��-�=� de�ze':
9503P (2013/11) Page 3 of 8
Schedule 1 - Contributions
Part I— Summary of Contributions
Contribution from candidate (include the value of inventory listed in Table 5)
Contribution from spouse
Total 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 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 cantributor exceeds $100 (do not includ�
contributions from candidate or spouse).
Less: Contributions returned or payable to the contributor
Contributions paid or payable to the clerk, including contributions from
anonymous sources exceeding $10
Totat Amount of Contributions (Record in Box C)
+ $ �;,,��, ��;' ,
t '� I/.iiQp
+ $ ; i={r.ti?ui
+ $ r>.1 i)0.00
— $ i.�0�.00
— $ C�.f3(i
_ $ ��,�f4��).9➢41 1A
Part II — List of Contributions from Each Single Contributor Totalling more than $100
Table 1: Monetary contributions from individuals other than candidate or spouse
Name Full Address
. . „ _,
.lames T�viss 9�7 Mountc �s�i�° � i���. ��ic� �,r��r<<�� �a���a_r-���� Ll� ,.�-�
`>l,�F:�;aES_. ��_ /`�,i-��.ac���� 9�.r;z,�+t�.ii:y
i',;�<:k��s_.a1�i� �'r�u:�
� % %5 �� !1`�?(�,F'1 ,��(�. ��P ��;4��� V1 �. "��S�i��YE'fiC1, E, V ", ! ";t�
;�7� ����ya���l�� '.,��:;. � r �_w�3'�i,i<. <>W�t:R�to. ��f 1�,`�
� I Additional information is listed on separate supplementary attachment
Total
Amount $
?5�.�9t)
`,OO.ti��
➢ Uf�.Cd�i
<;-,�:,'�,_ ,
9503P (2013/11) Page 4 of 8
Table 2: Monetary contributions from corporations or unions
Name (Legal and Carrying on Full Address
Business As)
�.
�..; ,,,. �. � i�� _ �- -..
Cei��, . � ���o��c>>�to. O»tario ui 1 p;' �'
FJunt ��,�b�_s� 4_�;=�_; 4 Pinoak Rd. /�ja:t,
Sevag Yehoyai� Bai� i�'E�:���
.sfc� � ,li �=�,,a.
Ontario, llt 21�
7� C�entre St. S., Suite 2(➢0�
�_ �sf�a�va., Ontario, I 1 h4a 1
President or
Business Manager
�4 .
J � : ...
i,,, � ;;_
�_� Additional information is listed on separate supplementary attachment
Authorized � Amount $
� :� t�;�(i
Total � i '`'t?.�9��
Table 3: 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 Value $
i or Services
❑ Additional information is listed on separate supplementary attachment
Total
9503P (2013/11) Page 5 of 8
Table 4: Contributions in aoods or services from
Name of Corporation Full Address
(Legal and Carrying on
Business Asl
corporations or unions (Note: must also be recorded as expenses in Box
President or Authorized Description of Value $
Business Manager Representative Goods or Services
L.f Additional information is listed on separate supplementary attachment
Total Part II Contributions (Add Totals from Tables 1-4) (Record in Part I— Summary)
Part III — Inventory
Table 5: Inventory of Campaign Goods and Materials from Previous Campaign used in this Campaign
Total
�,���?3����V1 B
❑ Additional information is listed on separate supplementary attachment
9503P (2013/11) Page 6 of 8
Schedule 2— Fundraising Events and Activities
Fundraising EventlActivity
G�m�le#e a �e�ar�te schedG!e for e�ch ss�en± er ac±i��Et� held
❑ Additional schedule(s) attached
Description of fundraising evenUactivity
Date of evenUactivity (yyyylmmldd)
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 X
Total Ticket Revenue (2A x 2B) (Include in Schedule 1)
Part II — 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 II Revenue (include in Schedule 1)
Part III — 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 III Revenue (include in Box C)
Part IV — Expenses related to fundraising event or activity (provide details)
1. +
2. +
3. +
4. +
5. +
6. +
7. +
8. +
Total Part IV Expenses (include in Box C)
$
$
$
$
$
$
$
$
��
26
_ $
_ $
_ �
_ �
9503P (2013/11) Page 7 of 8
Auditor's Report
Municipal Elections Act, 1996 (Section 78)
A candidate who has received contributions or incurred expenses in excess of $10,000 must attach an auditor's report.
Professional Designation of Auditor
Municipality
Contact Information
Name
Last Name
Address
Suite/Unit No. Street No.
Cityi i own
Street Name
Telephone No. (including area code) Fax No.
ext. I
First Name
Province
Email Address
Date (yyyy/mmldd)
��cer�ce NUm�er
Postai Gode
The report must be done in accordance with generally accepted auditing standards and must:
• set out the scope of the examination
• provide an opinion as to the completeness and accuracy of the financial statement and whether it is free of material
misstatement
� i Report is attached
Personal information, if any, collected on this form is obtained under the authority of sections 78 and 95 of the Municipal Elections Act,
1996. Under section 88 of the Municipal Elections Act, 1996 (and despite anything in the Municipal Freedom of Information and
Protection of Privacy Act) documents and materials filed with or prepared by the clerk or any other election official under the Municipal
Eler_tions Act 1996 are �u�fic records and, until the�r destructien, may be inspectec� Ly any per�on at thP �IPrk'� �.ff.ir_.e �t a tir�e when
the office is open. Campaign financial statements shall also be made available by the clerk in an electronic format free of charge upon
request.
9503P (2013/11) Page 8 of 8