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Home My WebLink AboutLaurissa Hraikir� � � . �r" Ontario Instructions: Ministry of Municipal Affairs and Housing Financial Statement - Auditor's Report Form 4 Municipal Elections Act, 1996 (Section 78) All candidates must complete Boxes A and Bo 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 excess of $10,000 must also attach an Auditor's Report, All surplu� funds (after any refund to the candidate or his or her spouse) shall be paid immediately over to the clerk who was responsible for the conduct of the election. YYYY MM DD For the campaign period from (day candidate filed nomination) I I I to �Primary fiNing reflecting �nances to December 31 (or 45th day after voting day in a by-election) ❑ Supplementary filing including finances after December 31 (or 45t" day after voting day in a by-election) Box A: Name of Candidate and Office Candidate's name as shov�n on the ballot Last Name Given Name(s) Name of office for which the candidate sought election � Ward name or noo (if any) Name of Municipality Spending limit issued by clerk �$ � _ � �; _ . YYYY MM DD [] I did not accept any contributions or incur any expenses other than the nomination fee, (Complete Box A and 8 only) Box B: Declaration � � �� =�� .��. , a candidate in the municipalit}r of , 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) in the C i C�-- 1 � on (yyyy/mm/dd) �O ��j � Cj j � a� ° �Y��'� �-l� Signature of Clerk or Commissioner '� p �5/ (� I ��'o Date Filed in the Clerk's Office (yyyy/mm/dd) �ISA DIANNE HARKER, a Commissioner,et�,RegionalMunicipal'Ry of Durham, fo�TheCorporationofthe Cityof Pickering. Expires Ja nua ry 28, 2018. -. ��.�q p r - � ff... r,y'�y, � Signature of Candidate 9503P (2013/1 1) O 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 Amount borrowed $ INCOIVIE Total 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. 3a iotal 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 of Schedule 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) 1a 2, 3, iotal 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) 1e 2e 3. Other (provide full details) 1. 2, 3. Total Expenses not subject to spending limit iotal Campaign Expenses (C2 + C3) 9503P (2013/11) + $ + $ + $ + $ + $ + $ + $ + $ _ � C1 + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + � + $ + $ _ $ C2 + $ + $ + $ + � + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ _ � C3 _ � C4 Page 2 of 8 : • � ` � � • � �;. Excess (deficiency) of income over expenses (Income — Total Expenses) (C 1 � C4) Eligible deficit carried forward by the candidate from the last election iotal (D1 — D2) If there is a surplus, deduct any refund of candidate's or spotase's contributions to the campaign Surplus (or deficit) for the campaign + $ _ $ _ $ � �. _ $ _ � D3 If line D3 shows a surplus, the amount rr►ust be paid in trust, at the time the financial statements are filed, to the municipal clerk who was responsible for the conduct of the electiona Amount of $ paid tn municipal clerk in the municipality of 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)e Total value of contributions exceeding $100 per contributor (from line 1 B; list details in Tables 1 — 4) • Include ticket revenue9 contributions in money, goods and services where the total contribution from a contributor exceeds $100 (do not include contributions from candidate or spouse)a Less: Contributions returned or payable to the contributor Contributions paid or payable to the clerk, including contributions from anonymous sources exceeding $10 Total Amount of Contributions (Record in Box Cj + $ + $ + $ + $ _ $ _ � _ $ 1A Part II — List of Contributions frorr� Each Single Contributor Totalling more than $100 Table 1: Monetary contributions from individuals other than candidate or spouse Name Full Address � Additional information is listed on separate supplementary attachment 9503P (2013/11) Total Amount $ Page 4 of 8 Table �: Monetary contributions from corporations or uniorrs Name (Legal and Carr�ring on ( Full Address Business As) President or I Authorized Business IVianager Representative ❑ Additional information is listed on separate supplementary attachment Table 3: Contributions in goods or services from individuals other than candidate or spouse (Note: must also be recorded as expenses in Box C) Total • . �, 9503P (2013/11) Page 5 of 8 Table 4: Contributions in goods or services from corporations or unions (Note: must also be recorded as expenses in Box C) Name of Corporation Full Address President or Authorized Description of Value $ (Legal and Carrying on Business Manager Representative Goods or Services Business As) � Additional information is listed on separate supplementary attachment Total I Total Part II Contributions (Add Totals from Tables 1-4) (Record in Part I— Summary) � 1 B Part I11— Inventory Table 5: .Inventory of Campaign Goods and Materials from Previous Campaign used in this Campaign (Note: value must be recorded as a contribution from the candidate and as an expense) Description Date Acquired Supplier Current Market Quantity Total Value $ (yyyy/mm/dd) Value $ � Additional informati�n is listed on separate supplementary attachment 9503P (2013/11) Total Page 6 of 8 Scheciule 2— Funciraising Evenfs and Activities Funelraising Event/Activity Carr�plete a separate schedule for each event or activiiy held ❑ Additional schedule(s) attached Description of fundraising event/activity Date of event/activity (yyyy/mm/dd) Par� 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 Ticket Revenue (2A X 2Bj (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)) 10 2a 3� 4e 5e Total Part II Revenue (include in Schedule �I ) + $ X + $ + $ + $ + $ + $ 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 e °� � 2, �° $ 3. + � 4� + � 5, + � iotal Part III Revenue (incl�de in Box C) Part IV — Expenses relateci to fundraising event or activity (provide details) 1. 2e 3a 4a 5. 6e 7, 8e Total Part IV Expenses (include in Box C) 9503P (2013/11) + $ + $ + $ + $ + $ + $ + $ + $ 2A 2B _ $ _ $ _ � ', Page 7 of 8 Auditor's Report . Municipai 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 Last Name Address Suite/Unit No. Street Noe City/Town Telephone No. (including area code) exte Street Name Fax Noa Province Email Address Date (yyyy/mm/dd) Licence Number Postal Code 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 � 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, 1996e Unde� section 88 of the Municipal Elections Act, 1996 (and despite anything in the Municipal Freedorr� 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 Elections Act, 1996 are public records and, until their destruction, may be inspected by any person at the clerk's office at a time when the ofFce is open. Campaign financial statements shall also be made available by the clerk in an electranic format free of charge upon requeste 9503P (2013/11) Page 8 of 8