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Home My WebLink AboutDeborah Bissettr� � �r" 4ntario Instructions: Ministry of Municipal Affairs Fltla11C1aI S'�atEtllellt - Auditor's Report and Housing 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 �oxes C, D, Schedule 1, and Schedule 2 as appropriate. Candidates who receive contributions or incur expenses in excess of $10,000 must also attaCh an Auditors Report. All surplus funds (after any refund to the candidate or his or her spouse) shall be paid immediately over to the clerk who was responsible for the conduct of the election. YYYY MM DQ; WYY MM DD � ` � � , , � � � � � For ihe campaign period from (day candidate filed nomirtation) _`,._ �.� f ��`d , . �e; to -�,�� ; � � � � .' - �Primary filing reflecting finances to December 31 (or 45�' day after voting day in a by-election) ❑ Supplementary filing including finances after December 31 (or 45th day after voting day in a by-election) Box A': Name of Candidate and OfFce Candidate's name as shown on the ballot Last Name � � � � � � � Given Name(s) � I _ o � � e � �v � Name ot office for which the candidate sought election � ' ' � �'�� N p � � : -�.�i °� �..,_ t��r'� .�' i "` � � p.. 9 /` i �,. Name of Munici�ty ^ � � S �.��a � �g' �_��, �� Spending�mit issued la�cle{k •� t _�$ ' _ ', �. � � . t � , . _-- , Ward name or no. (if 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 � financial statements and attached , a candidate in the municipality of , hereby declare that to the beSt of my knowledge and belief that these ng schedules are true and correct. - Declared before (clerk or commissioner) in the � �i� � � I �e,f'-�, �i/'\o,� on (YYYY/mm/dd) oZQ�(p � Cj 3 � �..3 ,�i,r/d�C� {� Signature of Clerk or Commissioner �o,� � �3�a.� Date Filed in the Clerk's Office (y ylmm/dd) =�m�l� �B�falb�� AR�ERm a ��mr�isssor�ar,�t�,ReglonalMunicipal'iry oi �u�Sqam, forTheCorpo€ationofthe City at PiCkBri�g, Ex�lres Jarouary 28, 2018. ; �. - � ) ��'� - '�� 1. c Signature of Ca ' � I / �� , °503P (2013/11) OO Queen's Pnnterfor Ontano, 20'13 . Disponible en franryais Page 1 of 8 Box C: Statemenf 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 frorri 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 inciude 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 ' ; "� B roch u res/flye rs Signs (including sign deposit) Meetings hosted Office expenses incurred until voting day Phone and/or Ihternet 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 aftervoting day Phone and/or Intemet 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) 95�3P (2013/11) + $ + $ ��<� + $ + $ + $ + $ + $ + $ _ $ C1 + � �4.J() ° + $ ' . , + �$ ' '. + $ + $ `)��) — + $ + $ + $ + $ + $ + $ + $ + $ + $ _ $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ _ $ C2 C3 lr�� :�. _ $ � `� �� C4 Page 2 of 8 Box D: Calculatian' of Surplus or Deficit ' Excess (deficiency) of income over expenses (Income — Total Expenses) (C1 — C4) + � D1 E(igible deficit carried forward by the candidate from the last election —$ D2 Tota( (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 =� 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 of $ paid to municipal clerk in the municipality of 8503P (2013/11) Pa e 3 of 8 9 Schedule 1 - Contributions Part I— Summary of Contributions Contribution from candidate (include the value of inventory listed in Table 5) +$ Contribution from spouse - + � Totai value of contributions not exceeding $100 per contributor • Inciude 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 contnbution from a contributor exceeds $100 (do not include , contributions from candidate or spouse). . +� Less: Contributions retumed or payable to the contributor —� Contnbutions paid or payable to the clerk, including confnbutions from anonymous sources exceeding $10 — � Toial Amount of Contributions (Record in Box C) _� 1A Part 11— List of Coniributions from Each Single Contributor Totalling more than $100 _ . . . _. . _...__ �__a�___ c__� :._J:__:J....�.. ..i{.....4L..... r,.r..�lir7�4�o �� cnn��cn � Page 4 of 8 9503P (2013/11) Table 3: Contributions in goods or services from individuals other than candidate or spouse 8503P (2013/11) Page 5 of 8 Tabie 4: Contributions in Name of Corporation (Legal and Carrying on Business As) goods or services from corporations or unions (Note: must also be recarded as expenses in Box C) Full Address President or Authorized Descriptian of Value $ Business Manager Representative Goods or Services � Additional information is listed on separate suppiementary attachment ToFal Part il 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 $ 0 Additional information is fisted on separate supplementary attachment Total Tofal $ Total Value $ 1B 85�3P (2013/11) Page 6 of 8 Schedufe 2- Fundraising Evenis and Activities Fundraising EvenfJActivity Complete a separate schedule far each event or activity held � Additional schedule(s) attached Description of fundraising evenUactivity Date of evenUactivity (yyyy/mm/dd) _ Part 1— 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) (Indude 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) + $ + $ + $ + $ + $ + $ + $ + $ 2A 2B _ $ _ $ _ $ _ $ 35�3P (20'13/11) 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. Professiorral Designation of Auditor Contact Information Last Name Address � Suite/Unif No. Street No CitylTown Street Name Province uate (yyyy/mm/tld) Licence Number Nostal C;ode Telephone No. (including area code) Fax No. Email Address ext. 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 1996. Under section 88 of the Municipa! Elections Act, 1996 (and despite anything in the Municipal Freedom of Information and Protection of Privacy Act) documents and materiafs filed with or prepared by the clerk or any other election official under the Municipal Elections Act, 1996 are pubfic recnrds and, uniil their destruction, may be inspected by any person at the clerk's office at a time when the office is open. Campaign financial statements shali also be made available by the cferk in an electronic format free of charge upon request. 3503P (2013/'11) Page 8 of 8