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HomeMy WebLinkAboutSherry Croteau K A R K H E C K BLOOMBERG LLP C H A R T E R E D ACCOUNTANTS 13 CHURCH STREET I.bLLP AURORA, ONT. L4G 1G5 K A R K H E C K T905.727.0400 B L O O M B E R G F905.727.0482 Auditor's Report Campaign to Elect Sherry Croteau: We have audited the Financial Statement - Auditor's Report Form 4 as .at December 31, 2010. These financial statements are the responsibility of Sherry Croteau. Our responsibility is to express an opinion on the financial statement based on our audit. We conducted our audit in accordance with Canadian generally accepted auditing standards. Those standards require that we plan and perform an audit to obtain reasonable assurance whether the financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statement. In our opinion, the financial statement present fairly, in all material respects, the financial position of the Campaign as at December 31, 2010 and the summary of campaign income and expenses for the period then ended in accordance with Canadian generally accepted accounting principles. 3ccP ie Xba.m P-B Authorized to practice public accounting by The Institute of Chartered Accountants of Ontario Chartered Accountants February 23, 2011 1. Lr Ontario Ministry of Municipal Affairs Financial Statement - Auditor's Report and Housing Form 4 Municipal Elections Act, 1996 (Section 78) I Instructions All candidates must complete Boxes A, B, C, D, E and F and Schedule 1. All candidates must complete Schedules 2, 3 and 4 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) 2010 01 05 to 2010 12 31 ❑ 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 Name of Candidate Last Name First Name Middle Initial Croteau Sherry L Mailing Address Suite/Unit No. Street No. Street Name 275 Stover Cres. City/Town Province Postal Code Pickering ON L1V 6R1 Telephone No. (incl. area code) Fax No. Email Address Business Home 905-831-4617 sherrycroteau@yahoo.com Name of office for which the candidate sought election Ward Name or No. (if any) City Council Ward 1 Name of Municipality City of Pickering Box B: Summary , of Campaign Income and Expenses 1. My spending limit (as issued by clerk) was - - - - - - - - - - - - - - - - - - - - 23,882.75 2. Surplus (or deficit) from previous election - - - - - - - - - - - - - - - - - - - - $ 3. Total contributions received (from Schedule 1) - - - - - - - - - - - - - - - - - - - Is 11,752.00 4. My total campaign expenses that were subject to the spending limit were (from Box C) - - - $ 11,386.15 5. My total campaign expenses that were not subject to the spending limit were (from Box C) - - Is 6. Total of all campaign expenses (from Box C) - - - - - - - - - - - - - - - - - - - $ 11,386.15 7. Election campaign surplus/deficit from current election (from Box E) - - - - - - - - - - $ 365.85 8. Contributions refunded to candidate or spouse (from Box E) - - - - - - - - - - - - - I 365.85 9. Amount paid to clerk (from Box E) - - - - - - - - - - - - - - - - - - - - - - Is 0.00 9503P (2010/01) © Queen's Printer for Ontario, 2010 Disponible en frangais Page 1 of 8 Box'C : Statement of Campaign Period Income and Expenses From To For Candidate YYYY MM DD YYYY MM DD 2010 01 05 2010 12 31 Sherry Croteau INCOME Candidate's surplus from immediately preceding election released by the clerk + $ 0.00 Contributions from candidate - - - - - - - - - - - - - - - - - - + $ 7,000.00 Contributions from spouse of candidate - - - - - - - - - - - - - - + $ 0.00 All other contributions - - - - - - - - - - - - - - - - - - - - - + $ 4,752.00 Revenue from fund-raising functions not deemed a contribution (from Schedule 2, Part III) - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Interest income - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Other (provide full details) 1. + $ 2. + $ 3. + $ Total Campaign Period Income - - - - - - - - - - - - - - - - - - - - - - - - - - _ Is 11,752.00 C1 EXPENSES (Note: include the value of contributions of goods and services) Expenses Subject to Spending Limit Advertising - - - - - - - - - - - - - - - - - - - - - - - - + $ 3,797.63 Bank charges - - - - - - - - - - - - - - - - - - - - - - - + $ 72.70 Brochures - - - - - - - - - - - - - - - - - - - - - - - - + $ 2,389.95 Interest on loan - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Inventory contributed to candidate's campaign (Schedule 3) - - - - - - + $ 870.00 Meetings hosted - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Nomination filing fee - - - - - - - - - - - - - - - - - - - - - + $ 100.00 Office expenses - - - - - - - - - - - - - - - - - - - - - - + $ 33.06 Phone and/or Internet - - - - - - - - - - - - - - - - - - - - + $ 0.00 Salaries and benefits/honoraria/professional fees - - - - - - - - - + $ 0.00 Signs + $ 3,529.56 Other (provide full details) 1. Printing + $ 593.25 2. + $ 3. + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ 11,386.15 C2 Expenses Not Subject to Spending Limit Accounting and audit - - - - - - - - - - - - - - - - - - - - + $ 0.00 Costs of fund-raising function (from Schedule 2, Part IV) - - - - - - - - + $ 0.00 Expenses related to compliance audit - - - - - - - - - - - - - - + $ 0.00 Expenses related to controverted elections - - - - - - - - - - - - + $ 0.00 Expenses related to recounts - - - - - - - - - - - - - - - - - + $ 0.00 Voting day parry / appreciation notices - - - - - - - - - - - - - - + $ 0.00 Expenses related to candidate's disability (provide details) 1. + $ 2. + $ 3. + $ Other (provide full details) 1. + $ 2. + $ 3. + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ C3 Total Campaign Period Expenses (C2) + (C3) - - - - - - - - - - - - - - - - - - - - - _ Is 11,386.15 C4 Excess (Deficiency) of Income over Expenses (C1) - (C4) - - - - - - - - - - - - - - - - _ Is 365.85 9503P (2010/01) Page 2 of 8 BOX-D Statement of Assets and Liabilities as at , 20 Assets Cash + $ 1,641.99 Accounts receivable - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Value of inventory retained (from Schedule 4) - - - - - - - - - - - - + $ 2,543.50 Other (provide full details) 1. + $ 2. + $ 3. + $ Total Assets - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ Is 4,185.49 Liabilities and Excess (Deficiency) of Income over Expenses Accounts payable - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Borrowings, overdraft - - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) 1. + $ 2. + $ 3. + $ Total Liabilities - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ Is Box E: Statementof Determination of:Surplus or Deficit and Disposition of Surplus" Part I - Determination of Surplus or Deficit Amount of excess (deficiency) of income over expenses (from Box C) - - - - - - - - - - - - - + $ 365.85 E1 Deduct: Any deficit carried forward by the candidate from immediately preceding election if the offices are with respect to the same jurisdiction - - - - - - - - - - - - - - - - - $ 0.00 E2 Surplus (or deficit) for the campaign period (E1) - (E2) - - - - - - - - - - - - - - - - - - - = $ 365.85 Deduct: Any refund of contributions to the candidate or spouse (only if there is a surplus) - - - - - - - $ 365.85 Total Determination - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ Is 0.00 E3 Part II - Disposition of Surplus If line E3 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. Surplus paid to the municipal clerk of the municipality of 0.00 Box F.: Declaration Sherry Croteau a candidate in the municipality of Pickering 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) i in the Ck-~ O P~Gl~er~ i~G. on (yyyy/mm/dd) ao l l / 0 ~Q L() Signature of Clerk or Commissioner i nature of Candidate Pik 1C) 3/CSI Date Filed in the Clerk's Office (yyyy/mm/dd) DEBBIE M. SHI_ EWS, CITY CLERK, CITY OF PICKERING, EX OFFICIO COMMISSIONER PURSUANT TO SECTION 1(2) OF THE COMMISSIONERS FOR TAKING AFFIDAVITS ACT. 9503P (2010/01) Page 3 of 8 Schedule 1 - Contributions Part I - Contribution Contribution from candidate - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ 7,000.00 Contribution from spouse - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Total from each single contributor totalling more than $100 • include all ticket revenue where ticket price exceeds $100 • include all goods and services where value exceeds $100" • do not include contributions from candidate or spouse - - - - - - - - - - - - - - - + 4,552.00 Total from each single contributor totalling $100 or less • include all ticket revenue where ticket price is $100 or less • include all goods and services where value is $100 or less' • do not include contributions from candidate or spouse - - - - - - - - - - - - - - - + $ 200.00 "Note: Goods and services must also be reported as expenses in Box C Less: Contribution returned or payable to the contributor - - - - - - - - - - - - - - - - - - $ Contribution paid or payable to the clerk - - - - - - - - - - - - - - - - - - - - - - $ 1A Total Amount of Contribution - - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ 11,752.00 Total contribution from anonymous sources - - - - - - - - - - - - - - - - - - - . - - - $ 1B Amount of contributions paid or payable to the clerk (1A) + (113) - - - - - - - - - - - - - - - _ $ 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 Address Amount Steve DeGuise 139 Indian Lake Road, RR#1 Elgin, ON $ 750.00 Andrew Beacom 29 Creekwood Cres. Whitby, ON $ 200.00 Warren & Ingrid Beacom 17 Brigadier Pl. Toronto, ON $ 652.00 Hedi & Walter Hoch 69 Wanita Dr Toronto, ON $ 750.00 Jack Siegal 2 Queen St. E Ste 1500 Toronto, ON $ 100.00 ❑ Additional information is listed on separate supplementary attachment Total $ 2,452.00 9503P (2010/01) Page 4 of 8 Table 2: Monetary contributions from unions or corporations Name (Legal and Carrying on Address' President or Cheque Signatory Amount Business As) Business Manager Picore Holdings Ltd. 80 Queen St Kingston, ON $ 750.00 Priority Submetering 1465 Pickering Parkway, Ste 100 A. Beacom A. Beacom Pickering, ON $ 700.00 ❑ Additional information is listed on separate supplementary attachment Total $ 1,450.00 Table 3: Contributions in goods or services (Note: must also be reported as expenses in Box C) Name "Address Goods or Services Amount Ashlyn King 79 Chalmers Cres. Ajax, ON Photos $ 100.00 Nadia Morel 832 Thornton Rd. N. Oshawa, Website development $ 750.00 ON ❑ Additional information is listed on separate supplementary attachment Total $ 850.00 Total Part 11 Contributions $ 4,752.00 9503P (2010/01) Page 5 of 8 Schedule 2 -.Fund-Raising Function ❑ Additional schedule for each event or activity held is/are listed on separate supplementary attachment(s) Date Description of event or activity YYYY MM DD No events Admission charge (per person)* (may not exceed individual contribution limit) - - - - - - - - - - $ 2A *If admission charge per person is not consistent, attach complete breakdown of all ticket sales. Number of tickets sold - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 26 Part I - Ticket Revenue Lines: (2A) x (213) (include in Schedule 1) - - - - - - - - - - - - - - - - - - - - - - - - Part II - Other Revenue Deemed A Contribution Provide full details (e.g., revenue from goods sold in excess of fair market value) 1. - - - + $ 2. - - - + $ 3. - - - + $ 4. - - - + $ 5. - - - + $ 6. - - - + $ 7. - - - + $ 8. - - - + $ Total Part II Revenue (include in Schedule 1) - - - - - - - - - - - - - - - - - - - - - - _ Is Part III - Other Revenue Not Deemed A Contribution Provide full details (e.g., contributions of $10 or less; revenue from refreshment sold at cost) 1. - - - + $ 2. - - - + $ 3. - - - + $ 4. - - - + $ 5. - - - + $ 6. - - - + $ 7. - - - + $ 8. - - - + $ Total Part III Revenue (include in Box C) - - - - - - - - - - - - - - - - - - - - - - - - _ $ Part IV - Expenses Related to Fund-Raising Function Venue - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Event advertising - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Food and drink - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Entertainment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) 1. - - - + $ 2. - - - + $ 3. - - - + $ 4. - - - + $ 5. - - - + $ 6. - - - + $ 7. - - - + $ 8. - - - + Total Part IV Expenses (include in Box C) - - - - - - - - - - - - - - - - - - - - - - - _ Is 9503P (2010/01) Page 6 of 8 Schedule 3 - Inventory of Campaign Goods and Materials (from Previous Campaign) Used in Candidate's Campaign Description Date Acquired Supplier Unit Value Quantity Total Value (yyyy/mm/dd) Rebar 2006/03/01 Boss Steel $ 3.00 100 $ 300.00 Corplast 2006/09/01 $ 10.00 30 $ 300.00 Corplast 2003/09/01 $ 10.00 27 $ 270.00 Total Value of Inventory from Previous Campaign Used in Candidate's Campaign $ 870.00 Schedule '4 - Inventory of Campaign Goods and Materials at The End of Campaign Description Date Acquired Supplier Unit Value Quantity Total Value (y y/mm/dd) Rebar 2006/03/01 Boss Steel $ 3.00 80 $ 240.00 Large Signs 2010/09/01 Sankets Can. $ 32.30 40 $ 1,292.00 Maximum Signs Small Signs 2010/09/01 Media Works $ 2.89 350 $ 1,011.50 i Total Value of Inventory of Campaign Goods and Materials $ 2,543.50 9503P (2010/01) Page 7 of 8 Auditor's' Report Municipal, Bections: Act, 1996 (Section 78) A candidate who has received contributions or incurred expenses in excess of $10,000 must attach an auditor's report. 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 Professional Designation of Auditor CA Municipality Date (yyyy/mm/dd) Aurora Contact Person Licence No. Last Name First Name Karkheck Jeremy Address Suite/Unit No. Street No. Street Name 13 Church Street City/Town Province Postal Code Aurora ON L4G I G5 Telephone No. (incl. area code) Fax No. Email Address 905 - 727-0400 ext. 225 905-727-0482 jarkheck@jskcapc.ca 9503P (2010/01) Page 8 of 8 rte. Ministry of Municipal Affairs Notice of Extension of Cam ai n Ontario and Housing p 9 Period - Form 6 Municipal Elections Act, 1996 (Sections 68, 82.1) ~ 1 1 ~ rat S 2 o Instructions K • 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 r ot~a~t S Mailing Address Suite/Unit No. Street No. Street Name City/Town Province Postal Code F1 ckp,rj V t~ . l Telephone No. (incl. a a code) Fax No. Email Address Business l Home 3S . ^r 5'kev~'~G►~o'~ac~~'/ Gvv~ Name of office for which the candidate sought election or the Ward name or no. (if any) question for which the registrant incurred expenses + l.VllV~(~(~ V~GtY~ Name of Municipality S~ of Declaration I, S~ et-r ~n C1'-C> the candidate/registrant mentioned above hereby give notice and declare to the clerk that I have a deficit and wish the campaign period to be extended in accordance with section 68. Declared before me at the ` _ ` of 1 l C. K C C vt c~ in the of this tom. day of 20 1 U C~ ILI Signature of Clerk Sign re of Candidate/Registrant Q_C)IC> o?ofo -1a -~o Date (yyyy/mm/dd) Date (yyyy/mm/dd) 10550P (2010/01) © Queen's Printer for Ontario, 2010 Disponible en franpis March 29, 2011 Debbie Shields City Clerk City of Pickering Pickering Civic Complex One The Esplanade Pickering, Ontario L1V 6K7 Dear Ms. Shields: Re: Closing of Campaign Period I Please be advised that the Campaign to Elect Sherry Croteau for the position of Ward 1 City Councillor is closed effective immediately. A Financial Statement-Form 4 supplemental filing is attached. The form reflects that there were no financial activities in the campaign during the period from December 31, 2010 to March 29, 2011. If there are any questions or concerns, please do not hesitate to contact me at 905-831-4617 or by e-mail at sherrycroteau(a~_yahoo.com. Sincerely, Sherry L. Croteau 275 Stover Crescent Pickering, ON L1V 6R1 Encl. r.~ Ontario Ministry of Municipal Affairs Financial Statement - Auditor's Report and Housing Form 4 Municipal Elections Act, 1996 (Section 78) Instructions All candidates must complete Boxes A, B, C, D, E and F and Schedule 1. All candidates must complete Schedules 2, 3 and 4 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) 2011 O1 01 to 2011 03 29 ❑ 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 45`h day after voting day in a by-election) Box A: Name of Candidate and Office Name of Candidate Last Name First Name Middle Initial Croteau Sherry L Mailing Address Suite/Unit No. Street No. Street Name 275 Stover Crescent City/Town Province Postal Code Pickering ON L1 V6R] Telephone No. (incl. area code) Fax No. Email Address Business Home 905-831-4617 sherrycroteau@yahoo.com Name of office for which the candidate sought election Ward Name or No. (if any) City Council Ward 1 Name of Municipality City of Pickering Box B: Summary of Campaign Income and Expenses 1. My spending limit (as issued by clerk) was - - - - - - - - - - - - - - - - - - - - $ 23,882.75 2. Surplus (or deficit) from previous election - - - - - - - - - - - - - - - - - - - - $ 0.00 3. Total contributions received (from Schedule 1) - - - - - - - - - - - - - - - - - - - Is 0.00 4. My total campaign expenses that were subject to the spending limit were (from Box C) - - - $ 0.00 5. My total campaign expenses that were not subject to the spending limit were (from Box C) - - $ 0.001 6. Total of all campaign expenses (from Box C) - - - - - - - - - - - - - - - - - - - $ 0.00 7. Election campaign surplus/deficit from current election (from Box E) - - - - - - - - - - $ 0.00 8. Contributions refunded to candidate or spouse (from Box E) - - - - - - - - - - - - - $ 0.00 9. Amount paid to clerk (from Box E) - - - - - - - - - - - - - - - - - - - - - - - $ 0.00 9503P (2010/01) © Queen's Printer for Ontario, 2010 Disponible en frangais Page 1 of 8 Box C: Statement of Campaign Period Income and Expenses From To For Candidate YYYY MM DD YYYY MM DD 2011 01 01 2011 03 29 Sherry L. Croteau INCOME Candidate's surplus from immediately preceding election released by the clerk + $ 0.00 Contributions from candidate - - - - - - - - - - - - - - - - - - + $ 0.00 Contributions from spouse of candidate - - - - - - - - - - - - - - + $ 0.00 All other contributions - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Revenue from fund-raising functions not deemed a contribution (from Schedule 2, Part III) - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Interest income - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Other (provide full details) 1. 00 + $ 0.00 2. 0 + $ 0.00 3. 0 + $ 0.00 Total Campaign Period Income - - - - - - - - - - - - - - - - - - - - - - - - - - C1 EXPENSES (Note: include the value of contributions of goods and services) Expenses Subject to Spending Limit Advertising - - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Bank charges - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Brochures - - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Interest on loan - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Inventory contributed to candidate's campaign (Schedule 3) - - - - - - + $ 0.00 Meetings hosted - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Nomination filing fee - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Office expenses - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Phone and/or Internet - - - - - - - - - - - - - - - - - - - - + $ 0.00 Salaries and benefits/honoraria/professional fees - - - - - - - - - + $ 0.00 Signs - - - - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Other (provide full details) 1. + $ 2. + $ 3. + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - = $ C2 Expenses Not Subject to Spending Limit Accounting and audit - - - - - - - - - - - - - - - - - - - - + $ 0.00 Costs of fund-raising function (from Schedule 2, Part IV) - - - - - - - - + $ 0.00 Expenses related to compliance audit - - - - - - - - - - - - - - + $ 0.00 Expenses related to controverted elections - - - - - - - - - - - - + $ 0.00 Expenses related to recounts - - - - - - - - - - - - - - - - - + $ 0.00 Voting day party / appreciation notices - - - - - - - - - - - - - - + $ 0.00 Expenses related to candidate's disability (provide details) 1. + $ 2. + $ 3. + $ Other (provide full details) 1. + $ 2. + $ 3. + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ C3 Total Campaign Period Expenses (C2) + (C3) - - - - - - - - - - - - - - - - - - - - - _ $ C4 Excess (Deficiency) of Income over Expenses (C1) - (C4) - - - - - - - - - - - - - - - - _ Is 9503P (2010/01) Page 2 of 8 Box D: Statement of Assets and Liabilities as at , 20 Assets Cash + $ 0.00 Accounts receivable - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Value of inventory retained (from Schedule a) - - - - - - - - - - - - + $ 0.00 Other (provide full details) 1. + $ 0.00 2. 0 + $ 0.00 3. + $ 0.00 Total Assets - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ Is Liabilities and Excess (Deficiency) of Income over Expenses Accounts payable - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Borrowings, overdraft - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Other (provide full details) 1. + $ 0.00 2. 0 + $ 0.00 3. + $ 0.00 Total Liabilities - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Box E: Statement of Determination of Surplus or Deficit and Disposition of Surplus Part I - Determination of Surplus or Deficit Amount of excess (deficiency) of income over expenses (from Box C) - - - - - - - - - - - - - + $ 0.00 E1 Deduct: Any deficit carried forward by the candidate from immediately preceding election if the offices are with respect to the same jurisdiction - - - - - - - - - - - - - - - - - $ 0.00 E2 Surplus (or deficit) for the campaign period (E1) - (E2) - - - - - - - - - - - - - - - - - - - = $ 0.00 Deduct: Any refund of contributions to the candidate or spouse (only if there is a surplus) - - - - - - - $ 0.00 Total Determination - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ 0.00 E3 Part II - Disposition of Surplus If line E3 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. Surplus paid to the municipal clerk of the municipality of 0 Box F: Declaration 1. VIA U a candidate in the municipality of - hereby declare that to the best of my knowledge and belief that these financial statements and attached supp ing schedules are true and correct. Declared before (clerk or commissioner) i in the ~Ail O ~ti K t-r y1 on (yyyy/mm/dd) a l o 3 Signature of Clerk or Commissioner gnature of Candidate 0 1 1 1 2~1 rLo Date Filed in the Clerk's Office (yyyy/mm/dd) DEBBIE M. SHIELDS, CITY CLERK, CITY OF PICKERING, EX OFFICIO COMMISSIONER PURSUANT TO SECTION 112) OF THE COMMISSIONERS FOR TAKING AFFIDAVITS ACT. 9503P (2010/01) Page 3 of 8 Schedule 1 - Contributions Part I - Contribution Contribution from candidate - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Contribution from spouse - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ 0.00 Total from each single contributor totalling more than $100 • include all ticket revenue where ticket price exceeds $100 • include all goods and services where value exceeds $100" 0.00 • do not include contributions from candidate or spouse - - - - - - - - - - - - - - - + Is Total from each single contributor totalling $100 or less • include all ticket revenue where ticket price is $100 or less • include all goods and services where value is $100 or less" • do not include contributions from candidate or spouse - - - - - - - - - - - - - - - + Is 0.00 "Note: Goods and services must also be reported as expenses in Box C Less: Contribution returned or payable to the contributor - - - - - - - - - - - - - - - - - - $ 0.00 Contribution paid or payable to the clerk - - - - - - - - - - - - - - - - - - - - - - $ 0.00 1A Total Amount of Contribution - - - - - - - - - - - - - - - - - - - - - - - - - - - = $ Total contribution from anonymous sources - - - - - - - - - - - - - - - - - - - - - - $ 0.00 I B Amount of contributions paid or payable to the clerk (1A) + (113) - - - - - - - - - - - - - - - = $ 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 Address Amount ❑ Additional information is listed on separate supplementary attachment Total $ 9503P (2010/01) Page 4 of 8 Table 2: Monetary contributions from unions or corporations • Name (Legal and Carrying on Address President or Cheque Signatory Amount Business As) Business Manager ❑ Additional information is listed on separate supplementary attachment Total $ Table 3: Contributions in goods or services (Note: must also be reported as expenses in Box C) Name Address Goods or Services Amount ❑ Additional information is listed on separate supplementary attachment Total $ 0.00 Total Part II Contributions $ 0.00 9503P (2010/01) Page 5 of 8 Schedule 2 - Fund-Raising Function ❑ Additional schedule for each event or activity held is/are listed on separate supplementary attachment(s) Date Description of event or activity YYYY MM DD Admission charge (per person)" (may not exceed individual contribution limit) - - _ _ _ _ _ _ _ _ Is 2A "If admission charge per person is not consistent, attach complete breakdown of all ticket sales. Number of tickets sold - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2B Part I - Ticket Revenue Lines: (2A) x (26) (include in Schedule 1) - - - - - - - - - - - - - - - - - - - - - - - - _ Is Part II - Other Revenue Deemed A Contribution Provide full details (e.g., revenue from goods sold in excess of fair market value) 1. - - - + $ 2. - - - + $ 3. - - - + $ 4. - - - + $ 5. - - - + $ 6. - - - + $ 7. - - - + $ 8. - - - + $ Total Part II Revenue (include in Schedule 1) - - - - - - - - - - - - - - - - - - - - - - Part III - Other Revenue Not Deemed A Contribution Provide full details (e.g., contributions of $10 or less; revenue from refreshment sold at cost) 1. - - - + $ 2. - - - + $ 3. - - - + $ 4. - - - + $ 5. - - - + $ 6. - - - + $ 7. - - - + $ 8. - - - + $ Total Part III Revenue (include in Box C) - - - - - - - - - - - - - - - - - - - - - - - - _ Is Part IV - Expenses Related to Fund-Raising Function Venue - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Event advertising - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Food and drink _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ + $ Entertainment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) 1. _ _ _ + $ 2. + $ 3. + $ 4. + $ 5. + $ 6. + $ 7. + $ 8. + $ Total Part IV Expenses (include in Box C) - - - - - - - - - - - - - - - - - - - - - - - _ Is 9503P (2010/01) Page 6 of 8 Schedule 3 - Inventory of Campaign Goods and Materials (from Previous Campaign) Used in Candidate's Campaign Description Date Acquired Supplier Unit Value Quantity Total Value (yyyy/mm/dd) Total Value of Inventory from Previous Campaign Used in Candidate's Campaign $ Schedule 4 - Inventory of Campaign Goods and Materials at The End of Campaign Description Date Acquired Supplier Unit Value Quantity Total Value (yyyy/mm/dd) Total Value of Inventory of Campaign Goods and Materials $ 9503P (2010/01) Page 7 of 8 i 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. 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 Professional Designation of Auditor Municipality Date (yyyy/mm/dd) Contact Person Licence No. Last Name First Name Address Suite/Unit No. Street No. Street Name City/Town Province Postal Code Telephone No. (incl. area code) Fax No. Email Address ext. 9503P (2010/01) Page 8 of 8