HomeMy WebLinkAboutKoober Nuckchedee�! �� s
/►-- �ry �o Ministry of Municipal Affairs Financial Statement - Auditor'S R�pOi�
y/�� �1 1��1 �� and Housing F o r m 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
excess of $10,000 must also attach an Auditor'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 I I � I t° I, I
� Primary filing reflecting finances to December 31 (or 45th 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 � Given Name(s)
Name
for which the candidate sought election
Name of Municipality
Spending limit issued by clerk
$
name or no. (f any)
I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and B only)
Box B: Declaration
�
, a candidate in the municipality 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 � � � � � 1 � k�.r � -v�.�
on (yyyy/mm/dd) aQ �� / d� � o�-� •
� ��.�-�.�1 d. �-+
Signature of Clerk or Commissioner
oZ.o 1, S l O?� l'o�.%
Date Filed in the Clerk's Office (yyyy/mm/dd)
qE6�l� I�. SF�l�Lf�S, CITY �LERK,
CI`6Y �� �'iCtCFRG�v�>
EX QF�I�I(� �GOMh/IiSSiONER
PURSUl�N3 T�} S�CilSJ(V 112)
OF THE COMMOS�I�f�ERS FOR
TAKING AFF1�3�V�TS ACT.
r
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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 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 ((ist details in Table 5
of Schedule 1)
Advertising
Brochures/flyers
Signs (including sign deposit)
Meetings hosted
OfFce 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.
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 andlor 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)
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+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
_ $ C1
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
_ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
C2
+ $
+ $
+ $
- � C3
_ � C4
Page 2 of 8
� • � • • � , • � -
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)
Ifi there is a surplus, deduct any refund of candidate's or
spouse's contributions to the campaign
Surplus (or deficit) for the campaign
+ � D1
— � D2
_ $
— $
_ $
D3
If fine 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 of $
paid to municipal clerk in the municipality of
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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 frorn 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)
+ $
+ $
+ $
+ $
— $
— $
_ $
Part 11— List of Contributions from Each Single Contributor Totalling more than $100
Table 1: Monetarv contributions from individuals other than candidate or spouse
Name
Full Address
� Additional information is listed on separate supplementary attachment
Total
1A
Amount $
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Table 2: AAonetary contribuiions from corporations or unions
�:ame (Legal and Carrying on Full ,Adairess President or Authorized Amount $
Business As) �usiness nAanager f2epresentative
� Additional information is listed on separate supplementary attachment
iabie 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
� Addifional information is listed on separate supplementary attachment
Total
Description of Goods
or Services
Total
Value $
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Table 4: Contributions in
Name of Corporation
(Legal and Carrying on
Business As)
goods or services frorn corporations or unions (Note: must also be recorded as expenses in Box
Full Address President or Authorized Description of Value $
_ Business Manager Representative Goods or Services
� 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
(Note: value must be recorded as a contribution from the candidate and as an expense)
Description Date Acquired Supplier Current Market Quantity
(yyyy/mm/dd) Value $
� Additional information is listed on separate supplementary attachment
9503P (2013/11)
Total
Total.
$
Total Value $
1B
Page 6 of 8
Schedule 2— Fundraisirag Events arad Act6viiies
Fundraising Event/Activity ,
Complete a separate schedule for each event or activity held
� Additional schedule(s) attached
Description of fundraising event/activity
Date of evenUactivity (yyyy/mm/dd)
Part 1— Ticket fZevenue
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 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.
TotaB Part II Revenue (include in Schedule 9)
+ $
X
+ $
+ $
+ $
+ $
+ $
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 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.
TotaB Part IV Expenses (inc9ude in Box C)
9503P (2013/11)
+ $
+ $
+ $
+ $
+ $
+ $
+ $
+ $
2A
2B
_ $
_ $
_ $
_ $
e
Page 7 of 6
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.
City/Town
Teleohone Na (incluc
Street No. I Street Name
area code) I Fax No.
ext.
First Name
Province
Email Address
The report must be done in accordance with generally accepted auditing standards and must:
Date (yyyy/mm/dd)
Licence Number
Nostal Gode
• 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,
1996. Under section 88 of the Municipal Elections Act, 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 IVlunicipal
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 office is open. Campaign financial statements shall also be made available by the clerk in an electronic format free of charge upon
request.
9503P (2013l11) Page 8 of 8
t �
} � .
�r" Ontario
Ministry of Municipal Affairs
and Housing
Notice of Extension of Campaign
Period - Form 6
Municipal Elections Act, 1996 (Sections 68, 82.1)
Instructions
• To be completed and filed with the clerk by candidates or registrants requesting an extension of the campaign period
due to a deficit.
• This notice must be filed on or before December 31 in the year of a regular election and 45 days after voting day in the
case of a by-election.
Name of Candidate and Office/Registrant and Question
Name of Candidate/Registrant ,
Last Name � First Name � Middle Initial
�� 1/ r �/ �,,'
l
Mailing Address
Suite�unii �vo.
_ ' _ �--�.-
Stre�t No. ' S�rec� �Sa�+�
y _ , - � �� �_ � , , . -- --
,., ,
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r
� p �- ' - - � 't � f -
�Y � � � -' %� Y /` � � � r � � � . � � ,i � - — �
City/Town Province Postal Code
�A } � ` _ ..y �, �(, _ � � � � �,.. � t / `� i � ` �° c_i �
Telephone No. (incl. area code) Fax No. Email Address `
Business Home � , �, , � �
-t� _ '.'��✓�;.������ �',i'°�'/ . �1��
���" f . � � - F ,
! � � � ' . a•• -
Name of office for which the candidate sought election or the question Ward name or no. (if any)
for which the registrant incurred expenses ,
y� i " *' / � �/`' /'-.�`` . f' � ` � _ '��' �,,.,, ''- � � e t:�� .
� �
Na,�ie of Municipality
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� f., ,,.� .
�_ �__ , :�_ --�_ i �:� � L.%� - --
a' _
1 ` �� r-
Declaration ���� ...%
i /J a
I, ';� . � � �� ; � ,/ � ,'� -. r � ; �- , the candidate/registrant mentioned above hereby give notice
._
,�
�.. � �= �; � ' �! �- ��. �� f-�
and declare to the clerk that I have a deficit and wish #he campaign period to be extended in accordance with section 68.
Declared before me
at the � �
of � i � �.�t n C�,,
in the �� �t�►'� of � c� (�-��, I.✓-;
this �� day of ����'�'%��U`��- , 20��
o����'-�, �/�'%-� .
��,
Signature, of Clerk or Commissioner
; �� ��" �� � = - -
� – , !` ; �� a �� � � ` > ,
( /,
_. _ — � s _ , d, ._ - -
Date (��y/mm/dd)
_-�-.
10550P (2013/11) O Queen's Printerfor Ontario, 2013 Disponible en fran�ais
���,� ���a���i�� �i�RKER,
a Cor�m'sssioner, etc., Regional Munidpality
of Durham, for The Corporation of the
Cityof Pickering.
E�cpires January 28, 20150
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Date (yyyy/mm/dd)
,�y-� .
� ►— Ministry of Municipal AfFairs
L�� Ontario and Housing
Instructions
Financial Statement - Auditor's Report
Form 4
Municipal Elections Act, 1996 (Section 78)
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 Auditor'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.
WW MM DD WYY MM DD
For the campaign period from (day candidate filed nomination) I ; [ � � •,1 � �, � I � ;' to ) C � =: I � " �= i'
❑ Prkmary filing reflecting finances to December 31 (or 45th day after voting day in a by-election)
/
�J 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 bafloi
Last Name Given Name(s)
_ r -° 1�
" ' �' 1
/'�
�
/"°, ,° � �� �' � /-t',!= � �J l= f �< , C �°� .� ? L�.
Name of office for which the candidate sought
� c' 'i r �"I' <' .� ! l c
Name of Municipality
�� % Ce� L = 1� //v
Spending limit issued by clerk
$
�>
Ward name or no. (if any)
.�-
�.;�' / L � �,,
�did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and 8 only)
Box B:'Declaration
I, _ '' ';� /°, �,,✓' �'/�.
��_
, a candidate in the municipality of
% ,•� �!�/'!'�j; /� , hereby dedare that to the best of my knowledge and belief that these
financial statements an�attached supporting schedules are true and correct.
Declared before (clerk or commissioner)
in the G� � ��C.:�-� '�.�
on (yyyy/mm/dd) a(�l'J / ��1'� �� •
. -.. �
ao
Date Filed in tt
of Clerk or Commissioner
s
IISA DIANNE HARKER,
a Commissioner,eta,RepipnalMun(ciperity
of Oufiam, tor7AeCoiporetbno(the
Cityof ►icke�ing.
ExpiresJanuary 28, 2018.
-- -----�..----�._�,
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