HomeMy WebLinkAboutPeter Tijiri��
�/'►--� • Ministry of Municipal Affairs Financial Statement - Auditor�S ��pOi'�
6✓�� Ontario and Housing
Form 4
Municipal Elections Act, 1996 (Section 78)
. .ructions:
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
excess of $10,000 must also attach an Audito�'s 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 of the election.
YYYY MM DD YYYY MM DD
For the campaign period from (day candidate filed nomination) I ,�% ��`'�` �'�� Zw'-=% to I ,3-�; �'�'`" �' <�? ��� r�
❑ Primary filing reflecting finances to December 31 (or 45`h day after voting day in a by-election)
❑ Supplementary filing including finances after December 31 (or 45th 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 � �J o f� � I Given Name(s) �� d��`
e of office for which the candidate sought election Ward name or no. (it ;
,-•
�""� � � �: ��-r�' �;�r ���;� „�'• �r/�::� �
Name of Municipality
� � ,�� �.: �`� � 3Y �
Spending limit issued by clerk
c-
� � � � �,
$ ��� �- �
[J I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and e only)
Box B: Declaration
� ��'�,,W-,"J-, ',d �-�"� ��' r;�'� vE'-,� , a candidate in the municipality of
`=- t� ���'�°� �" , hereby declare that to the best of my knowledge and belief that these
t ; c;,� �, �:.. 9 ,� �:- _.
financial statements and attached supporting schedules are true and correct.
Declared before (derk or commissioner) ; ,
4_
inthe � `'.,����.'=�'v� ' �� ,� �`��_;��
on /mm/dd � •
iYYYY ) > f : � � l `�` ' � I
f.
�
Signature of Clerk or Commissioner
v
Date Filed in the Clerk's Office (yyyy/mm/dd)
��8���� � SH'I���1S,CITYCL�RIC,'
�ITi 1( OF PICK�RI�1G,
EX OFFICIO COM�v1�SalONER
PURSUANi TCA SECI�ION 1421
�OFTHE COMMIS�IONERS FOFi
TAKING AFFICeAVITS ACT.
� �.
Signature of Candidate
/
8503P (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
Amount borrowed $
INCOME
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 ill 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
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, professionai fees incurred until voting day
Bank charges incurred until voting day
Interest charged on loan until voting day
Other (provide full details) .
,•"`w' �
� 1. �i^( Fi��t'��. a l�� I`ii �� �
2. r i,� c /3 .S � � �
3. _ �%�''� �l� r` `'. .`Y ��}}riarae rt'4� ✓�� �u� A-G. � /�°i �:rr'r'
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)
2.
3.
Total Expenses not subject to spending limit
Total Campaign Expenses (C2 + C3)
3503P (2013/11)
+$ ��...1��°��;
+ $ �@y�:e �
+ $
+ $
+ $
+ $
+ $
+ $
_ � :�k': �•�����` C1
+ � �,�� ��
+ $
+ $ �_����_
'�' � ✓"�, �i�- Ci i� • i; "'i�
+ $ �` eS'i; d:) � t'J�:
+ $ ���-�,.��
+ $ ��:..�` r`,� �:�
+ $ .`� `� ..� ^
+ $
+ $ e�Z� � d�
+ $
+ $ �.�5 '�,i'
+ � �°� �: a �; �
+ � � � � �: ° �a:.
° � �', i °°?� � ' �` � C2
--�
+ $ �"e c� • c��c�
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
_ $ ,�"�,� �k . �,�:, � C3
_ $ ��,�� '�'�°� C4
Page 2 of 8
�ox D: Calculation of Surplus or Deficit
Excess (deficiency) of income over expenses (Income — Total Expenses)
(C 1 — C4)
Eligible deficit carried forward by the candidate from the last election
I (D1 — DZ)
Ifi there is a surplus, deduct any refund of candidate's or
spouse's contributions to the campaign
Surplus (or deficit) for the campaign
+ $ � �; �: � �' ��--� D 1
— $ D2
_ $ �� �, � .�
— $
_ $ t� �'�C �3° ��- D3
If line D3 shows a surplus, the amount must be paid in trust, at the time the financiai statements are filed, to the municipal clerk who was
responsible for the conduct of the election.
Amount of $
paid to 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).
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 include
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
Total Amount of Contributions (Record in Box C)
+ $ .:� ��'(� ` �8�,�
+ $ /°, � �.� • �- �,
+ $ ���'=�<�:
+ � �, cr� >} � ° �:i t�`'
- $
- $
= $ �A . ':� a; �, : L t� 1 A
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
Pi° ,� �:. u�9 G..�i �.� r � S e'' :�.- ,:� =,+'�'I e,q v� �✓ �� �
�P� �i� ��"P v r°� �f���c
.�-.6 � �� S � / �
y�`� i," 'i�. Jl'� � �t.� � ��-� A`� �t 6 U�P i �-- r i +� (...` � � '`�5 l.
%� J'`- G P"i � C` f�; y;;�° b� ��P d;-`
�� ea r
�� � �� �e v ,� r �.� � � r c �,�� ��-�� � � �: � P � �:
�
�'e��,� � re �; � � c�� i� ;� m � � c
d� � �. � • -
e `"! .:.� a:; G� i`� y r�% t� .� r"i, �`�' d �e� � G�,r�i i
,�'d G,�C �= �. S re �'i- �; � �"� / !�-� a e`�
�9`� :�.��
�`-`,y�' ra � ��`z r%!`f 1�.�i J �J ,# � e� a.°'r'C�'S t=�.-� s' 1
���C_ C�O�• /rv!'v'I. �.l tv" �f�:ii�
�"!'Y � `��„ ��
,� � ��' � ='�? y� ..,�7 r �� �,3 � �..j �S � d.t..-,"W d�9 �.---�'7 � < ��+°+,. �'
_ d
` s�;,�-;�,� � i<< t:.� �r`°t��, C� e� f�i*��Cs
�"✓li✓� �r��
� � � �,� t �� r°!�r'` � I ��,�,� �� � �x �' �� r r�� �; � i c E � _ � r �e' am=
�� t: ✓�`�' u� � P�: t� d;: �= �� E�'" n�,� �,�r� �` �
✓ � / ,�-u� .� l:.: ")
f� ��' � a t+� 4 Q'� V, � ..J" C:s'� �� �W %� "� ;
� y' t; F� L�`^� ,�C� �� v� d!'��r �
,�9, �. 3 a� ��
-�f � � �' �- � .� c� � �. ��-P �`+ r � �° �, �-
/Gti�'L'4�r�� �'rd 1�t'f✓
_ � s�l r ✓� .� �.� �
r c�. Lv i��r �o J
C p'-✓�O:A� °:-d�' � t° �'"_ i�/ C> �f 6' °�-bd ��
Additional information is listed on separate supplementary attachment
9503P (2013/11)
�
�-�� - Total
Amount $
�� 4 ��
°� �; g'a, �;
��` ��� ����
���°�a�
°� �: � ° �. C
-.� 9� ' f,'e�
,;�-_� _ �.:C
���`�'�
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�-�.: °��:
,�C€"°�'�
Page 4 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 s�Ees
where the total contribution from a contributor is $100 or I�ss (do not
include contributions from candidate or spouse). �' �
Total value of contribufions exceeding $100 per co�r #ributor (from line 1 B; list details
in Tables 1 — 4) ,,!
• Include ticket revenue, contributions in,rrioney, goods and services where
the total contribution from a contributor exceeds $100 (do not include
contributions from candidate o�pouse).
Less: Contributions returne�%r payable to the contributor
Contributions pa �or payable to the clerk, including contributions from
anonymous urces exceeding $10
Total Amountyf'Contributions (Record in Box C)
+ $
+ $
+ $
+ $
— $
_ $
Part 11= 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
�.,��"��a»: r'%� ��' �s���- ��'`�,' ��a'a✓3C � r'�ea. .�
a �/� :�
�s° u°' t" s , ( C'_ ��; �.�.,' <9'r~P �-�s
j yt � � .� � I � . � ��'' i d�d5� � � a'� � � ;' �"���
� 6`�� �' � c�, �a �` �-��'-� �i r� �`.�7 6 � � � � � `� � 9�°�' � �
���°�d � � �- � �
��� ����
,� `� � � i�9 %�f-i-��►",� ✓' �y` _�-'� �',�'�� .� '��`'2 i��: as'
�o � dC a:.��� � �� t� J`�t ✓'�� � �
�'' � tr� .� s� I
�'` �--�- � ✓� -� / � � •� �` r .� �; � S; � � E"� : L, <+�' i `�' e'� �
i✓ �,
✓� �`� � S S ✓�-t-d a�y � u�P d"'r'�r� i�
� �- °��. � ,� '
�. f -� •v r � - >�` .�; cx r -S` / :�� �" �J� C:� �V r-�� �= m� r � d � m5 r'�:
� � er � �
/ i c.-x �� � t-� G, � � �' �'
�' r e� ,�°'�` �
✓`,' �: � �-_- � .:�' cL � � � � � � � r� �C' ��,��
S c:d�2u� f.� � r`� � e;� �` r�� C� ✓�i � i� � r�
/! r �, �- �` �
�� P�`�- a:� �`� r�-:'�P ::� r e.; ,� i C�� �,•v �" `� � r'�--� a
� �� � d ,� �: � �-� ��-�. � c�
�� 6 �
� y 6+. d� Gv '�.
� Additional information is listed on separate supplementary attachment
9503P l2013/111
1A
Amount $
.�_ �z � ,. r° :.
�-�.� ry��
�,> �a �r, n �, �
�� �
���w..��
y'�d,�` I � � ��y�;
�-�; , �, �`�
�~�'rv��
TOt3� I �° � `..i �C.3 M q`; ��+
� �
Paoe 4 nf R
Ta61e 2: Monetary contributions from corporations or unions
Name (Legal and Carrying on Full Address President or
Business As) Business Manager
� Additional information is listed on separate supplementary attachment
Authorized Amount $
Representative
Total
able 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 $
or Services
C; �tV U [,? ,�,�'=" ; f' �� �-'-s�"d-t' ✓v � S�r y� �-�' ; °� 1�Ji'"l �?a': dr.5 r' d�' �� �C��e.% %� ' '�' �"
i% t"V. ����A7 iy�i � i i��/ li
G�
�i % +'!� .�
j•�rr7�'�a � ,� �- �' �, r�s �' .� �,I /yJ �' ,f' � -r � � ,t� � �
F
%�' !' C--%�_ l~--�i °� G✓ c^. f% % ���"''s / CW ,� 0 �� .� �..,� WC'�' ' . 6�.. r
�e j t-L �; 2.%_
0'" I 1 C/�/' Y.y �� ✓°°. C: S� _y ,y' � C`� iC,�%� Y��' v� c-.�i. -
w aAn2�t �',�"Cs ° ��
eil ��P'T 13 � � C ,, � ,�s�-a^P � � r+ �i
��7 r :3 C .
, � � L�._ ,f G° ,� '� 6 � �y` �r2 �� � n ,�. � � ���- �
� r� � t �, <� r .°) �".. a' �; ��-..Ci '`J �y-''�' i .S i ri G�- ..� a� � � �` �°
f G�t:: R i
� � � _ `�
tC ii�Z C:--�� �=�2 ,'� Ut .S 3�`. �7 �=-d :A IJ �. �� f� c-�a�,'�" (:��i°T� �v� i 4 v�
!r / i�it'� �..5-d� ,�` �i L'" , t:i �'t �a'ir Qy y '�= 9 �u ° ��f;>
vr i �' � �`' - �' ���7`+' �=F � c�= d� � �' r"
r,� � �d � , �'�d� �c �- ,;2 �!..i(/,,�,_ i �, <� �-�= �'�� �S' � . @�
iL.% t'�= ✓ d `r �, rr' � ���`d�-t d:: iR�d-. �S � W ��- ....5� �. " � �:
� 1 �� ' � �:
J� � t= 'ri � y°,v' r �!'�t �5 ,� ::z ,.,,,`�-tL " i aE=' t'7� - � ,�,,, � � / v,r ��` � :.� � � " S.' W
.r
,S � G�f�-/� j� G C. �; ��� i`�'� � o �P „ � � �e - v. �
d � / � � t'`r` � d � �` � t�
- ��- 'r �+ � ��-� i' � ° <.� � v � .-�,�.���. ��r � � �_ � �; � �
�,- „
r�,, t:���,� '�%�-
���G ✓�� ,�a o c� ,; [7
�/J� �'��
f�y�'"a. _. �73 �tl i Z� '1 ,��' � � ati G����' ���P �. .� '��
.� � � C�% ��` / f i� � �a .�d�. C" L�
�a
�'� �e- t--z��- � � '`
,� r �, �'�� .� �'�� r� �`� .�
['o�`�Additional information is listed on separate supplementary attachment ,`�,-c,�� •- Total ��; 'a ,� �� ��`i��
9503P (2013l11)
Page 5 of 8
1"able 2: Monetary contributions from corporations or unions
f�ame (Legal and Carrying on Full Address President or Authorized
Business As) Business Manager Representative
„�" 't7 � i ��� r%,�i-� i`� �:. � ru - � �--� � ��, �` � >�..j�,�`'
���Z ° `"���' n ,. �
� � ;�°�-t�; %�V , r�ods_ � a�,. ��v� � �d�J u��u��'
� Additional information is listed on separate supplementary attachment
Total
Amount $
"'e 3: Contributions in goods or services from individuals other than candidate or spouse
(Note: must also be recorded as expenses in Box C)
hlame Full Address Description of Goods Value $
or Services
,- � s f � � � �.� � � � �-1;s- j L,4� c �; .�'��,f�. � /' � � ' � �' �'; � ��,�
�� �e � � �:,��.
.��� �;�
�� T.��. �- �- e r � �
� �; �9 � �;� „ � �
'�'Cs � i: ;�'i �; . L? r� e`� �' "� � �
C�r�fi�-�i��'�� ��'�',� ��G,� ;��(�����/�'�,.a-� ��a,�r��:��
� �,�L� o !? �; �'.� G�, �;r rd lr3 v � y ' �" �'�;�.� d`�--� �; � �;�i^
�'aif��� r'a� ,Q;�� � �t' �" d'i �-�a" L% �z,,v✓,� ,�"t.� /�-�
� c%�`�= �' �.� � c: �:� � P� ; � 4 r d�i i'..�i �� ��- ,�� �=`-�„��' ���� a' � � i:;
�] Additional information is listed on separate supplementary attachment
Total I ,�'�� � �� � �;
o503P (2013/111
Page 5 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
Last Name
Address
Suite/Unit No. Street No.
City/Town
Telephone No. (including area code)
e�.
Street Name
Fax No.
Province
Email Address
Date (yyyy/mm/dd)
cence
Nostal 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 statemenf�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 Municipa( Elections Act,
1996. Under section 88 of the Municipal Elections Acf, 1996 (and despite anything in the Municipal Freedom of Information and
Protection of Privacy Acfl documents and materials filed with or prepared by the clerk or any other election official under the Nlunicipal
Elections Act, 1996 are pubiic records and, until their destruction, may be inspected by any person at the clerk's office at a time 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.
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