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Home My WebLink AboutTate Bessor�� l.�l IO Ministry of Municipal Affairs FIC1a11CIaI StatetllEllt - Auditor's Report and Housing Form 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 conduct bf the election. YYYY MM DD YYYY MM DD , _ " � For the campaign period from (day candidate filed nomination) ,-�; to �(� 0 Pnmary 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�lection) Box A: Name of Candidate and Office Candidate's name as shown on the ballot Last Name � � Given Name(s) Name of office for which the candidate sought election Ward name or no. (ff any) Name of Municipality N Spending limit issued by clerk $ � I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and 8 only) Box B: Declaration I, j , 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 � � �-N �-� �, G�� , ytic� on (yyyy/mm/dd) 1 v�Q �(� � � Z� o�, 5 • � . �, . °\ ..�..o Signature of Clerk or Commissioner �-C� ti b l 0� I�,S _ � ��pE ��. ��@��.6_CIS, CITY CL!ERK, �I'�'Y CiIF �O�;sy��3N�, Fat OFFiC�(.� Gf19Vl�li�SI�IVER Pt..1RSUANT TQ SE�;T90fV 712) OF THE CpfV]MISSIUNERS FOR iAiC��1C� A�FID,4i/!TS AC�f. � �.,�....�., led in the Clerk's Office (yyyy/mm/dd) Signature of Candidate 9503P (2013/'11) OO Queen's Printer for Ontano, 20'!3 Disponibfe en franrtais Page 1 of 8 Box C: Statement of Campaign:lncome 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 contribufion (From Part III of Schedule 2) Interest eamed by campaign bank account OtF�er (provide full details) 1. 2. 3. Total Campaign Income (Do not inciude loan) EXPENSES (Note: include the value of contribufions 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 ofSchedule 1) Advertising B roch u res/flye rs 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) 1. 2. 3. Total Expenses subject to spending limit Expenses not sut�ject 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 ekpenses 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) 1. 2. 3. T�tal Expereses not subject to spending (imit Total Campaign Expereses (C2 + C3) 9503P (2013/11) + $ + $ + $ + $ + � + $ + $ + $ _ $ � " C1 + $ ; �_ + � + $ � + $ ; _ + $ + $ + $ + $ + $ + $ �. �` + $ + $ + $ + $ _ $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ _ $ C2 C3 _ � � C4 Page 2 of 8 Box D: Calculation of Surplusor Deficit Excess (deficiency) of income over expenses (Income — Total Expenses) (C1—C4) + � ; .n��. � D1 Eligible deficif carried forv✓ard by the candidate from the last election —$ D2 Total (D1 — D2) _ $ If there is a surplus, deduct any refund of candidate's or � spouse's contributions to the campaign —$ Surpius (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 95�3P (20'13/�1) Page 3 of 8 Schedule 1 - Contributions Part I— Summary of Contri6utions Contribution from candidate (include the value of inventory listed in Table 5) Contribuiion from spouse Totai 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 contribufion from a contributor exceeds $100 (do not include contributions from candidate or spouse). Less: Contributions retumed or payable to the confributor Contributions paid or payable fo the derk, including contributions from anonymous sources exceeding $10 Total Amount of Contributions (Record in Box C) i :- +��;:; + $ ; + $ + � � ., — $ ,, — $ - � _ 1A Part 11 — List of Contributions from Each Single Contributor Totalling more than $100 °5�3P (2D13/1'I ) Paae 4 of S Table 2: Nlonefiary contributions from corporations or unions Table 3: Contributions in goods or senrices from individuals other than candidate or spouse 8503P (2013/11j Pa e 5 of 8 4 Table 4: Contributions in goods or services from corporations or unions (Note: must also be recarded as expenses in Box C) Name of Gorporation Fulf Address President or Authorized Descriptian of Va(ue $ (Legal and Carrying on Business Manager Representative Goods or Services Business As) __ � Additional information is listed on separate supplementary attachment T°�� I Total ParE II Contributions (Add Totals from Tables 1-4) (Record in Part I- Summary) � � B Part III - Inventory Tabte 5: Inventory of Carnpaign Goods and Materials from Previous Campaign used in this Campaign 85�3P (2013/� 1) Page 6 of 8 Schedufe Z— Fc��€iraising Events and Activities Fundraising Event/Activity Comp{eYe a separate schedule for each event or aciivity held � Additional schedule(s) attached Description of fundraising evenbactivity Date of event/activity (yyyy/mm/dd) Part 1— Ticket Revenue Admission charge (per person) (ff there are a range of ticket prices, attach complete breakdown of all ficket sales) + $ Number of tickets sold X 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. Total Part II Revenue (include in Schedule 1) + $ + $ + $ + $ + $ Part fll — 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 _ $ _ $ _ $ _ $ 85�3P (20t3/11) Page 7 of 8 Auditors 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 Desiqnafion of Auditor Municipality Contact Information Last Name Address � Suite/Unit No. Street No. City/Town Telephone No. (including area code) ext. Street Name Fax No. Province Email Address Date (yyyy/mm/dd) Licence Postal Code The report must be done in accordance with generaliy 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 a�d whether it is free of material misstatement � Report is attached Personal information, if any, callected on this form is obtained under the authority of sections 78 and 95 of the Municrpal Elecfions Act, 1996. Under section 88 of the Municipal Elections Acf, 1 S96 (and despite anythi�g in the Municipal Freedori� of lnformation and Protecfion of Privacy Act) documents and materials filed with or prePared by the clerk or any other election officiai under the Municipal Electiorrs Act, 9396 are pubfic recorcfs and, unfil 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. 3503P (2013/11) Page 8 of 8