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HomeMy WebLinkAboutIda Fogo C~ The Corporation of the City of Pickering Pickering Civic Complex PICK E R I I G One The Esplanade (v Pickering, ON L1 V 6K7 1811 BICENTENNIAL 2011 cityofpickering.com Administration Department Legal & Legislative Services Division - Clerk's Office T. 905.420.4611 Toll Free 1.866.683.2760 TTY 905.420.1739 Fax 905.420.9685 Email clerksQacityofpickering.com March 28, 2011 SENT VIA REGISTERED MAIL Ida Fogo 1818 Dencourt Drive Pickering, ON L1V 4Y2 Subject: 2010 Municipal Elections - Financial Statement - File: A-2000-001-11 TAKE NOTICE that you are in default of the requirements of the Municipal Elections Act, 1996, as amended, because you failed to file documents, namely your financial statement, with the City Clerk as required by Section 78 of the Municipal Elections Act, 1996, as amended, on or before 2:00 p.m. on Friday, March 25, 2011. As a result, you are now ineligible to be elected or appointed to any office to which the Municipal Elections Act, 1996, as amended, applies until the next regular election has taken place in 2014. If you have any question regarding this matter, please feel free to contact me directly at 905.420.4660 ext. 2019. Yours truly hJ J Debbie Shields City Clerk DS:kn I r i 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 a campaign, period from (day candidate filed nomination) a0 10 O a d to Q0 10 1 a 3 Primary filing reflecting finances to December 31 (or45`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 FOOD Mailing Address Suite/Unit No. Street No. Street Name 18 8 N tvZ City/Town Province Postal Code T cie7 egI Al ON FlK10 1 ✓ Telephone No. (incl. area code) Fax No. Email Address Business Home 9(aJ - q ~0-3~ 40 t p( Logo o-ho Q Name of office for which the candidate sought election Ward Name or No. (If any) ge- C Ras T L-c Pc 51 r; Name of Municipality 1--i A W1 Box B: Summary of Campaign Income and. Expenses 1. My spending limit (as issued by clerk) was - - - - - - - - - - - - - - - - - $ 1¢ 6. X7,9. 30 2. Surplus (or deficit) from previous election - - - - - - - - - - - - - - - - - - - Fs-- 3. Total contributions received (from Schedule 1) - - - - - - - - - - - - - - - - - s ILj. ~9 4. My total campaign expenses that were subject to the spending limit were (from Box C) - - - s 5 7 1 • g 5. My total campaign expenses that were not subject to the spending limit were (from Box C) - - s 680 • 00 6. Total of all campaign expenses (from Box C) - - - - - - - - - - - - - - - - - - - s 7. Election campaign surplus/deficit from current election (from Box E) - - - - . - - - - - Is --e~r- 8. Contributions refunded to candidate or spouse (from Box E) - - ; - - - - - - - - - - F -,gyp . 0 Q 9. Amount paid to clerk (from Box E) - - - - - - - - - - - - - - - - - - - - - Is 9503P (2010101) © Queen's Printer for Ontario, 2010 Disponible en fran~ais Page 1 of 8 Box C: Statement of Campaign Period Income and Expenses From To - For Candidate YYYY MM DD YYYY MM DD INCOME Candidate's surplus from immediately preceding election released by the clerk + $ Contributions from candidate - - - - - - - - - - - - - - - - - - + $ 0 0 Contributions from spouse of candidate - - - - - - - - - - - - + $ 1 o• 00 All other contributions - - - - - - . - - - - - - - - - - - - - - + $ 3 . 3 Revenue from fund-raising functions not deemed a contribution (from Schedule 2, Part III) - - - - - - - - - - - - - - - - - - - - - + $ 3?$•d~ Interest income - - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) _ 1. + $ 2. + $ 3. + $ Total Campaign Period Income - - - - - - - - - - - - - - - - - - - - - - - - - - _ Is 4 I .3 C1 EXPENSES (Note: include the value of contributions of goods and services) Expenses Subject to Spending Limit Advertising - - - - - - - - - - - - - - - - - - - - - - - + $ Bank charges - - - - - - - - - - . - - - - - - - - - - - - + $ Brochures - - - - - - - - - - - - - - - - - - - - - - - + $ ( (28-16 Interest on loan - - - - - - - - - - - - - - - - - - - - - - + $ Inventory contributed to candidate's campaign (Schedule 3) - - - - - - + $ Meetings hosted - - - - - - - - - - - - - - - - - - - - - + $ 1.50-00 Nomination filing fee - - - - - - - - - - - - - - - - - - - - + $ ( D • Office expenses - - - - - - - - - - - - - - - - - - - + $ 304 • QD Phone and/or Internet - - - - - - - - - - - - - - - - - - - - + $ 1941-62 Salaries and benefits/honoraria/professional fees - - - - - - - - - + $ Signs - - - - - - - - - - - - - - - - - - - - - - - - - - + $ 6 C70 Other (provide full details) 1. + $ O.p 2. + $ 3. - + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - _ is 3. Jc ►11 • CT C2 Expenses Not Subject to Spending Limit Accounting and audit - - - - - - - - - - - - - - - - - - - - + $ Costs of fund-raising function (from Schedule 2, Part IV) - - - - - - - - + $ X80 0O Expenses related to compliance audit - - - - - - - - - - - - - - + $ Expenses related to controverted elections - - - - - - - - - - - + $ Expenses related to recounts - - - - - - - - - - - - - - - - + $ Voting day party / appreciation notices - - - - - - - - - - - - - - + $ a 50 • o o Expenses related to candidate's disability (provide details) 1 + $ 2. + $ 3. + $ Other (provide full details) 1. + $ 10©•44 2. + $ 60- nn 3. + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ 4 C3 Total Campaign Period Expenses (C2) + (C3) - - - - - - - - - - - - - - - - - - - - - _ $ • 2. 5 C4 Excess (Deficiency) of Income over Expenses (Cl) - (C4) - - - - - - - - - - - - - - - - = $ 9503P (2010/01) Page 2 of 8 Box D. Statement of Assets and Liabilities as at , 20 z • Assets Cash - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Accounts receivable • - - - - - - - - - - - - - - - - - - - - + $ Value of inventory retained (from Schedule 4) - - - - - - - - - - - - + $ Other (provide full details) 1. + $ 2. + $ 3. + $ Total Assets - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Liabilities and Excess (Deficiency) of Income over Expenses Accounts payable - - - - - - - - - - - - - - - - - - - - - - - + $ Borrowings, overdraft - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) 1. + $ 2. + 3. + $ Total Liabilities - - - - - - - - - . - - - - - - - - - - - - - - - - - - - - - _ Is Box E: Statement of Determination of Surplus or Deficit. and Disposition of Surplus Part 1- Determination of Surplus or Deficit _ Amount of excess (deficiency) of income over expenses (from Box C) - - - - - - - - - - - - + $ E1 Deduct: Any.deficit carried forward by the candidate from immediately preceding election if the offices are with respect to the same jurisdiction - - - - - - - - - - - - - - - - $ E2 Surplus (or deficit) for the campaign. period (E1) - (E2) - - - - - - - - - - - - - - - - - = $ Deduct: Any refund of contributions to the candidate or spouse (only if there is a surplus) - - - - - - - $ . Total Determination - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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 Box F: Declaration I, 1 G 01 F0 9 p a candidate in the municipality of 1 c\c:rr i ✓1 a 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'A N O-S ~t G\K'Gt t on (yyyy/mm/dd) ap l1 ~C~ LI a1 V .Cl Signature of Clerk or Commissioner Sig ure of Candidate aC~.1 1 b L4 l I el, =r Date Filed in the Clerk's Office (yyyy/mm/dl) ' a-■ DEBBIE M. SHIM, CITY CLERK, CITY OF PICKPING, EX OFFICIO MISSIONER PURSUANT SECTION 1(2) OF THE COMMISSIONERS FOR 9503P (2010ro1) TAKING AFFIDAVITS ACT. Page 3 of 8 Schedule 1 - Contributions j Part I - Contribution Contribution from candidate - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Q O~ Contribution from spouse - - - - - - - - - - - - - - - - - . - - - - - - - - - + $ 00• © O 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 - - - - - - - - - - - - - - + $ 6 ~L5. 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 - - - - - - - - - - - - - - - + Is 1, 0.. .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 - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ Total contribution from anonymous sources - - - - - - - - - - - - - - - - - - - - - $ 1 B Amount of contributions paid or payable to the clerk (1A) + (18) - - - - , - - - - - - - - - - - _ $ 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 ~o~~E ~~~c °1 St1oRE >~v~ big. io2ovia. ov rn `C 391 $,200.00 E t ~W AB $ 200.00 04- H. - v * cAmj E-t,.-, ~Ro% d. o TD • Mir 3r-P $ 540 - © 0 plgm 6DI W t 11Iftmg 1~ rz-~ouA C-965 ti Lis `?C 5 $ i 25• o d $ $ $ $ $ $ $ $ $ $ $ $ $ $ ❑ Additional information is listed on separate supplementary attachment Total $ l 9503P (2010101) Page 4 of 8 Ta'ble 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 36 '&?Bone cxcrt $ G3 } b~6K t~l1~KK.t S~/4~ ~ AX ON U~flu~ t=bol~ FvK ~w~ Isa~ ~ 5O ~ oO 15 1 CAN C Oe&S nlsV~ f rAli° . AOA . ON LIT- 4k 3 ObBE Foo Troll Fuu,> WimSeR $ 13© OD KcNi~ 1 cK C I~I~NCE t ~'1 H DE,v ZD • 5 FAC.r;SODK gFr up RNA IDPW n, 00- M19 36-u EAI AN CE 147 0 c70 $ ❑ Additional information is listed on separate supplementary attachment Total g Total Part II Contributions 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) - - - - - - - - - - $ 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 (2121) (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 11 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. FFt~rlllt,( ~AcK N f~R~unlc`(ioN - - + $ 3 5.® 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) - - - - - - - - - - - - - - - - - - - - - _ $ 80.0v 9503P (2010/01) Page 6 of 8 Sche6ule 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 Y /mm/dd) Total Value of Inventory of Campaign Goods and Materials $ 9503P (2010101) Page 7 of 8 Y Auditor's Report Municipal E/ections'Act, 1906 (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 No. No. (incl. area code) Fax Email Address ext. 9503P (2010101) Page 8 of 8 Ministry of Municipal Affairs Notice of Extension of Campaign IV Ontario and Housing 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 xo t Jfi Mailing Address Suite/Unit No. Street No. Street Name lg 8 t ,,v coue7" b)~ VF CityfTown Province Postal Code Telephone No. (incl. area code) Fax No. Email Address Business Home , I C/A 74~ ~0,ov /4 A 00 - CQ. Name of office for which the candidate sought election or the Ward name or no. (if any) question for which the registrant incurred expenses Name of Municipality II Declaration 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 C of P i Gh2 r1 n o~ in the Ml2D~'t n of D w- K cam this -s day of ULP_Cjafnbe.T 20 LO Signature of Clerk `Signatu of Candidate/Registrant 10 « O a of 0 f,2 S6 Date ( yyy/mm/dd) Date ( yyy/m /dd) I i 10550P (2010101) © Queen's Printer for Ontario, 2010 Disponible en frangais I April 19, 2011 Further to the filing of an Extension of Campaign Period please be advised that I have completed my campaigning for the 2010 Elections and attached is my Supplementary Filing Form 4 which is the same as my Primary Filing. Ida Fogo Ministry of Municipal Affairs ~ ' Ontario and Housing Financial Statement - Auditor's Report Form 4 Municipal Elections Act, 1996 (Section 78) No t i C s i a l o -9, CC, mpc.' g vt Instructions Per 1U0~ CO t ~Pr't l°i~ll SLA.PPI GUhc04'~'_~, j 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 Ft 1 v%c~ .p appropriate. Candidates who receive contributions or incur expenses in excess of $10,000 must also attach an Auditor's Report Pi' t M0.ir S c~nn r~ X5 All surplus funds (after any refund to the candidate or his or her spouse) shall be paid immediately over to the clerk w o was res nsib for the conduct of the election. YYYY MM DD YYYY MM ;D;D For the campaign period from (day candidate filed nomination) to 1 1 01Y+ Vg0t 1 O L4 I. cc v% imary filing reflecting finances to December 31 (or45" day after voting day in a by-election) Vpplementary 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 roCo I~~ Mailing Address Suite/Unit No. Street No. Street Name City/Town Province Postal Code O c- E9 1 Al D1V 119110 Telephone No. (incl. area code) Fax No. Email Address Business Home l~ Ago ~ a" a Name of office for which the candidate sought election Ward Name or No. (tf any) 1. pus i cc Pe nJ4T .9c P 0 15> Name of Municipality uK 1-+arv1 - Box B: Summary of campaign Income and Expenses _ 1. My spending limit (as issued by clerk) was. - - - - - - - - - - - - - - - - - - - $ 1}(,• `.?Yq 30 2. Surplus (or deficit) from previous election - - = - - - - - - - - - - - - - - - - - $ 3. Total contributions received (from Schedule 1) - - - - - - - - - - - - - - - - Is q 1~ . a 4. My total campaign expenses that were subject to the spending limit were (from Box C) - - - $ 3, 5 71 • 8 f' 5. My total campaign expenses that were not subject to the spending limit were (from Box C) - $ 680.0o 6. Total of all campaign expenses (from Box C) - - - - - - - - - - - - - - - - - - - $ t} `~5 g 7. Election campaign surplus/deficit from current election (from Box E) - - - - - - - - - - 8. Contributions refunded to candidate or spouse (from Box E) - - - - - - - - - - - - I O o . o 67 9. Amount paid to clerk (from Box E) - - - - - - - - - - - - - - - - - - - - - - 9503P (2010101) © Queen's Printer for Ontario, 2010 Disponible en franpais Page 1 of 8 Box C: Statement of Campaign Period Income' and Expenses ' From To For Candidate YYYY MM DD YYYY MM DD INCOME Candidate's surplus from immediately preceding election released by the clerk + $ Contributions from candidate - - - - - - - - - - - - - - - - - - + $ 100,00 Contributions from spouse of candidate - - - - - - - - - - - - + $ t 0©• All other contributions - - - - - - . - - - - - - - - - - - - - - + $ 61 . 39 Revenue from fund-raising functions not deemed a contribution (from Schedule 2, Part III) - - - - - - - - - - - - - - - - - - - - + $ 375••6Q Interest income - - - - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) 1. + $ 2. + $ 3. + $ Total Campaign Period Income - - - - - - - - - - - - - - - - - - - - - - - - - EXPENSES (Note: include the value of contributions of goods and services) Expenses Subject to Spending Limit Advertising - . - - - - - - - - - - - - - . - - - - + $ Bank charges - - - - - - - - - - - - - - - - - - - - - - + $ Brochures - - - - - - - - - - - - - - - - - - - - - - - + $ ( . j Interest on loan - - - - - - - - - - - - - - - - - - - - - - + $ Inventory contributed to candidate's campaign (Schedule 3) - - - - - - + $ Meetings hosted - - - - - - - - - - - - - - - - - - - - - + 1.50. 4® Nomination filing fee - - - - - - - - - - - - - - - - - - - + $ 100-00 Office expenses - - - - - - - - - - - - - - - - - + $ AD Phone and/or Internet - - - - - - - - - - - - - - - - - + $ Salaries and benefits/honoraria/professional fees - - - - - - - - + $ Signs - - - - - - - + $ ~i-78 0 Other (provide full details) 1. + $ 5o.o 2. + $ Q 3. + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - _ $ 3. J • C5 ,1 C2 Expenses Not Subject to Spending Limit Accounting and audit - - - - - - - - - - - - - - - - - - - - + $ Costs of fund-raising function (from Schedule 2, Part IV) - - - - - - - - + $ 80 Q0 Expenses related to compliance audit - - - - - - - - - - - - - - + $ Expenses related to controverted elections - - - - - - - - - - + $ Expenses related to recounts - - - - - - - - - - - - - - + $ Voting day party / appreciation notices - - - - - - - - - - + $ 50. p0 Expenses related to candidate's disability (provide details) 1 + $ 2. + $ 3. + $ Other (provide full details) 1. + $ t O0. 00 2. + $ 100 3. + $ Subtotal - - - - - - - - - - - - - - - - - - - - - - - - - - 0 C3 Total Campaign Period Expenses (C2) + (C3) - - - - - - - - - - - - - - - - - - - - - = C4 Excess (Deficiency) of Income over Expenses (C1) - (C4) - - - - - - - - - - - - - - - - = $ 9503P (2010101) Page 2 of 8 Boz D: Statement of Assets and Liabilities as at , 20 Assets Cash - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Accounts receivable . - - - - - - - - - - - - - - - - - - - + $ Value of inventory retained (from Schedule 4) - - - - - - . - - - - - - + $ Other (provide full details) 1. + $ 2. + $ 3. + $ Total Assets - - - - - - - - - - - - - - - - - - - - . - - - - - - - - - - - _ Liabilities and Excess (Deficiency) of Income over Expenses Accounts payable - - - - - - - - - - - - - - - - - - - - - - + $ Borrowings, overdraft - - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) + $ 2. _ + $ 3. + $ Total Liabilities - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - = I 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) - - - - - - - - - - - + $ E1 Deduct: Any deficit carried forward by the candidate from immediately preceding election if the offices are with respect to the same jurisdiction - - - - - - - - - - - - - - - - $ E2 Surplus (or deficit) for the campaign period (E1) - (E2) - - - - - - - - - - - - - - - - _ Deduct: Any refund of contributions to the candidate or spouse (only if there is a surplus) - - - - - - - $ . Total Determination - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ E3 Part 11 - 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 Box F: Declaration I, ck a G p a candidate in the municipality.of C_ V_ t~ r L' Y1 c, 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 on (yyyy/mm/dd) ~O (l Zo 1-1 19 Signature of Clerk or Commissioner Sig ure of Candidate " G-C>.1 1 /G L4 n Date Filed in the Clerk's Office (yyyy/mm/d,1) DEBBIE M. SHI 1S, CITY CLERK, CITY OF PICKING, ,wa EX OFFICIO O_WMISSIONER PURSUANT it SECTION 10 OF THE COMMISSIONERS FOR 9503P (2010/01) TAKING AFFIDAVITS ACT. Page 3 of 8 Schedule 1 = Contributions Part I - Contribution Contribution from candidate - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ i© 10C Contribution from spouse - - - - - - - - - - - - - - - - - . - - - - - - - - - + $ )pQ• Q Q Total from eachr 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 - - - - - - - - - - - - - - + $ 6 lac 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 - - - - - - - - - - - - - - - + $ : • ' 0 '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 - - - - - - - - - - - - - - - - - - - - - - - - - - = $ Total contribution from anonymous sources - - - - - - - - - - - - - - - - - - - - - $ 1 B Amount of contributions paid or payable to the clerk (1A) + (1 B) - - - - - - - - - - - - - - - = $ 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 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 $ < r ;r f~F; ~ ` i f-'r t . tom' f ~ ~ F;J ~(~..G~~ + _ ~ is ~ f'~ ~ e°`J¢; ! ~~ii a"~ J . i 6 t /4 Al C-iEF, --I rt t`~` OUj Z) 57 K,r levtJ Q. Jam' fA)Ifi r1lQ;s+tJ AtANC, $ $ $ $ ❑ Additional information is listed on separate supplementary attachment Total $ Total Part II Contributions $ aq 0rp 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) - - - - - - - - - - $ ~.}•~9C~' 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 (21B) (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) 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) 2. - - + $ 3. - + $ 4. - + 5. - + $ 6. - + $ 7. + $ 8. - + $ Total Part III Revenue (include in Box C) - - - - - - - - - - - - - - - - - - - - - :37 5 Part IV - Expenses Related to Fund-Raising Function Venue - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Event advertising - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Food and drink - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + 06 Entertainment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + $ Other (provide full details) 1. + $ 2. - - + $ 3. - - + $ 4. + $ 5. + $ 6. - + $ 7. - + $ 8. - + $ Total Part IV Expenses (include in Box C) - - - - - - - - - - - - - - - - - - - - - - ;80 .0v 9503P (2010,101) 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) $ $ I $ $ 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 (y /mm/dd) Total Value of Inventory of Campaign Goods and Materials $ 9503P (2010/01) 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. 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 (2010101) Page 8 of 8