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Home My WebLink AboutChris van der Vliet�/i� • � , Nlinistry of Municipal Affairs F'IClc'�CiCic'3� t�t� �tl� - udAt�riS � O {i � and Housing F�C 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 �oxes 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 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 co�duct bf the election. YYYY MM DD YYYY MM DD _�^' Forthe campaign periad from (day candidate filed nomination) (�'� �' x '� � �� to �� ' 4�'� . , ,, Primary filing refle�ting finances to December 31 (or� 45"' 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 P Given Name(s) k�� l �`"' � � � �'� � .! "� �r � � Name of office for which the candidate sought election Ward name or no. (if any) . � M� �, _ ,� y , , 4 s�� '`;� �''�� '`�a�� Name �- � � ,� Spe�,nd' g limit issued $ ''�, � � � e � I did not accept any contributions or incur any expenses other than the nomination fee. (Comptefe Box A and B only) Box.B: Declaration ,. , , , , _ I, � ��'"��;'� �;�� `"�,�r' � � � ; �,�` , a candidate in the municipality of �'�� ' �� '; � , hereby declare that to the best of my knowledge and belief that these financial statements and attac ed supporting schedules are true and correct. Declared before (clerk or commissioner) in the � ��_�QS �� (1 Q, on iYYYYImmldd) �o `to 1 d � � � ( , . � Signature of Clerk or Commissioner �. O \ lQ / c�3 l�� % Date Filed in the _ lerk's ffice (yyyy/mm/dd) �� „�� "� � � � � � , � �u � �; � ��7 d ;� � ,. �� t �� Signa re of idate 'e � ommr�onar�,eeY�C.��ERal�lunicipality o� �iurham, forTheCqrppr�tioo ofihe ��of Pic&ering. Expfres January zg, 20f �. 9503P (2013111) OO Queeds Printer for Ontario, 2013 . Disponibfe en fran�ais Page � of 8 Box C: Statement of Campaign Income and Expenses LOAN ' Name of bank or recognized fending insfitution Amaunt borrowed $ 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 (pravide 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 Schedufe 1) Advertising Brochures/flyers Signs (inciuding sign deposit) Meetings hosted Office expenses incurred unfil voting day Phone and/or Internet expenses incurred until voting day Salaries, benefrts, honoraria; professional fees incurred until voting day Bank charges incurred until voting day Interest charged on loan until voting day Other (provide full details} 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 O�ce expenses incurred after voting day Phone and/or Intemet expenses incurred after voting day Salaries, benefits, honoraria, professio�al fees incurred after voting day Bank charges incurred afte� 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 timit Total Campaign Expenses (C2 + C3) 9543P (2013l11) + ��µ��=�� + � � CC°»JC� �' � + $ + $ + $ � + $ + $ + $ _ �� #_� � " C1 + $ � �_ ��° + $ + "$ + $ + $ + $ + $ + $ + $ + $ + $ + � � � t� � ° $ ._ ` C2 �f"1 �� + $ � + $ + $ + $ + $ + $ + $ �� + $ + $ + $ + $ + $ + $ + $ + $ + $ ± � --� . �3 �� _ $ . 4 Page 2 of 8 Box D; Calculatian of Surplus ar Deficit ; Excess (deficiency) of income over expenses (I�come — Total Expenses) �"�� (C1 — C4) + $ � pq Eligible deficit carned forward by the candidate from the last election —$ p2 � � Tofal (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 = $� � � � 3 � ` If Iine 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. Amounf of $ paid to municipal clerk in the municipality of 8503P (20�3/11) Page 3 of 8 Scheduie 1 - Contributions Part 1— Summary of Contributions Contribufion 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 senrices 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; fist 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 orspouse). . Less: Contributions retumed or payable to the contributor Contributions paid or payable to fhe derk, induding contributions from anonymous sources exceeding $10 Total Amount of Contributions (Record in Box C} + $ �� + $ + $ + � � �� — $ _ $ ��3 "� 1A Part II — List of Contributions from Each Single Contributor Totalling more than $100 iable 1: Monetary contributions from individuals other than candidate or spouse 95Q3P (2013/� 1) � Page 4 of 8 Table 3: Contributions in goods or seevices from individuals other than candidate or spouse (Note: must also be recorded as expenses in Box C) . � 3503P (2013/1 �) Page 5 of 8 Table 4: Contributions in Name of Corporation (Legal and Carrying on Business As) goods or senrices from 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 infarmation is Iisted on separate supplementary attachment Total Part II Contributions (Add Totals from Tables 1-4) (Record in Part I— Summary) Part III —lnventary Table 5: (nventory of Carnpaign Goods and Materiats 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 fisted on separate supplementary attachment Total Total $ Total Value $ 1B 8503P (2013/11) Page 6 of 8 Schedule 2— Funciraising Events and Activities Fundraising Event/Activity Compleie a separate schedute for each event or activity held � Additional schedule(s) attached Description of fundraising event/activity Date of event/activity (yyyy/mm/dd) � �'`� ' Part 1— Ticket Revenue �. �,� Admission charge (per person) � `� � � �t'.� '�""��'`'� �� " � (If there are a range of ticket prices, attach mplete breakdown of all ticket sales) + $ ` 2A Number of tickets sold X ��,�s�� _ 2B � Tofal Ticket Revenue (2A X 2B) (Include in Schedule 1) _$ i�� .�' �j �j 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) 4 � � � � � + $ + $ + $ + $ + $ ParE 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. + $ Tota'1 Part III Revenue (include in Box C) Part IV — Expenses related to fundrais� ,. �� .� C�. 2. <_ 3. � 4. 5. 6. 7. 8. Total Part IV Expenses (include in Box C) event or activity ( rovide details) ��n�,� + � ��..� � � + $ + $ + $ + $ + $ + $ + $ _� �� u � °�," � - ��'i _ $ _ $ _ $ �; - C� 85Q3P (2013/1'1) Page 7 of B `Audito�'s Report Municipal Elections A�t, 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 Municipality Contact Information Last Name _ Add ress Suite/Unit No. Street No. City(Town Telephone No. (including area code) e�. Street Name Email Address Date (yyyylmmldd) Licence Number 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 � Report is attached Personal information, if any, collected on this form is obtained under the authority of sections 78 and 95 of the Municipal Elecfions Act, 1996. Under section 88 of the Municipal Elections Acf, 1996 (and despite a�ything in the Municipal Freedom oflnformafion and Protecfion of Privacy Act) documents and materiais filed with or prepared by the clerk or any other election official under the Municipal Elections Act, 1996 are pubfic reco.rds and, until their destruction, may be inspected by any perso� at the cierk's office at a time when the office is open. Campaign financial statements shall alsa be made available by the clerk i� an electronic format free of charge upon request. 8503P (2013/11) Page 8 of 8