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Home My WebLink AboutCorey Bessor�j j� . �' Ontail0 Ministry of Municipal Affairs and Housing Financial Statement - Auditor's Report Form 4 Municipal Elecfions 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 Boxes 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 Audito�'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. YYl(Y MM DD WW MM DD For the campaign period from (day candidate f led nomination) � �S� ��-- � ��;-� � ,� �'n� � t° � ��,� � � � -�=�� ,' ,� � �-� � � � 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 45th day after voting day in a by-election) �ox A: Name o� Candidate and �ffice Candidate's name as shown on the ballot Last Name �� ''�� b� g _ Name of office for which the candidate sought election �� ' irr, .� �` �..:-� ?��d' ��.e '% �'.:��y 9 �'� � .�' 1'"J�.�_ i ti��V . : Name of Municipality � � � �-' � � r �� '� � ` � � � �- �-- @ ; � � E'��.�, . � Spending I�mit issued by clerk � ,��s : �_ -�;, � ,� � ,�-- � _ � >i �._� o r, ��' i I` z $ �:; � _.# ;,� 1y • - + Given Name(s) �� J _ ... f. •�.w.'.� 4�-- Ward name or � (if any) � I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and 8 only) Box B: Declaration . `- - = - ��= �-� , a candidate in the municipality of ,� �� g �;�� `'`��`; ��` ;�-� r;'L�r"�, , hereby declare that to the best of my knowledge and belief that these financial s atements and attached suppo�fing schedules are true and correct. Declared before (clerk or commissioner) � in the C i Q� 1 C��i on (yyyy/mm/dd)� oi� �� I • c�.��f�'.1 J� Signature of Clerk or Commissioner ao�s oa Date Filed in the Clerk's 0 ice ( /mm/dd) tISA DIANNE HARKER, a Commissioner,etc.,RegionalMunicipality of Durham, b� The Corporation of the Cityof Pickering. ExpiresJanuary 28, 2018. / ? � "' ' \ � �� l � , � _ �� , Signature nf Candidate 9503P (2013/11) O Queen's Printer for Ontario, 2013 Disponible en franrais Page 1 of 8 _ _ _ Box C: Statement of Campaign �ncome and Expenses ` LOAN Narne of bank or recognized lending institution � Amount borrowed $ �; �r' INCOME ` Total amount of afl 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 (provide full details) � 1. 2. 3. To#al 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 Schedule 1) Advertising Brochures/flyers Signs (inc(uding 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 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 after voting 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 disabifity (Provide full details) 1. 2. 3. Other (provide full details) 2. 3. Total Expenses not subject to spending lirnit Toial Campaign Expenses (C2 + C3) 9503P (2013/11) - + � E � ��' � +$ �� + � � ��. + $ � . + $ + � ,�� + � , �'�.� .�� _ � 1�� C1 --�--� + � ° % �� + � u�� + � � ,��,�� 1 �� + � �� ,�� + � >`� �� 7� + � 1� '� + $ � �� + � �'"� �'� + $ ,� { � + � �� m� �� + � � �� + $ + $ �, + � �. _ $ �g ��.�� C2 �,o_i + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ + $ _ � C3 _� ��° '��;� c4 � Page 2 of 8 r'.: ,. , , . � . d � • ; :� . �, � .. £ : Excess (deficiency) of income over expenses (Income — Total Expenses) (C 1 — C4) Eligible deficit carried forward by the candidate from the last election � 1"otai (D1 — D2) I� there is a surplus, deduct any� refund of candidate's or spouse's contributions to the campaign Surplus (or deficit) for the campaign + � � � � ° �;� D 1 — $ D2 _ � j�,�� — $ j��k�� _ � 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 e(ection. 4 a Amount of $ � paid to municipal clerk in the municipality of 9503P (2013/11) Page 3 of 8 Schedule 1 - Contributions � Part I— Summary of Contributions Contribution from candidate (include the value of inventory listed in Table 5) Contribution from spouse Total v'alue 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 contribution from a contributor exceeds $100 (do not include contributions from candidate or spouse). Less: Contributions returned or payable to the contributor Contributions paid or payable to the clerk, including contributions from anonymous sources exceeding $10 Tota( Amount of Contributions (Record in �ox C) + � �� + $ + $ ,�. + $ — $ � a — � � � _ $ �a�� 1A Part 11— List of Contributions from �ach Single Contributor Totalling more than $100 Table 1: Monetary contributions from individuals other than candidate or spouse � Additional information is listed on separate supplementary attachment 9503P (2013l11) Page 4 of 8 T�b�� 2: �netaey cor�tribu�ions from carporations or u�ions �arne (Legal and Carrying on Full Address President or Aufhorized �enount � Business As) �usiness araager Representative � Additional information is listed on separate supplementary attachment Table 3: Contributions in goods or seovices from individuals other than candidate or spouse (Note: must also be recorded as expenses in Box C) i� Full Address � Additional information is listed on separate supplementary attachment Total Description of Goads or Services 1� Value � 8503P (2013/11) Page 5 of 8 Tabfe 4: Contributions in goods or services frorn corporations or unions (Note: must also be recorderl as expenses in Box C) Name of Corporation Full Address President or Authorized Description of Value $ (Legal and Carrying on � Business Manager Representative Goods or Services Business As) _ _ � Additional information is listed on separate supplementary attachment - Total I Total Part 11 Contributions (Add Totals from Tables 1-4) (Record in Part I- Summary) � � B Part III - lnventory 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 Total Value $ (yyyy/mm/dd) Value $ � Additional information is listed on separate supplementary attachment �otal 9503P (2013/11) Page 6 of 8 Schedule 2— Fundraisirag Events and ctiv6ties F�ndraising Event/Acfiivity Compiete a separate schedule for each event or activi�y held [� Additional schedule(s) attached Description of fundraising event/activity Date of event/activity (yyyy/mm/dd) Part I — 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 Totat Ticket Revenue (2A X 2�) (Include in Schedu{e 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 Par# II Revenue (inc�ude in Schedule 1) + $ X + $ + $ + $ + $ + $ Part ill — 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 �ox C) Part iV — Expenses related to funciraising event or ac�ivity (provic9e de�ils) 1. 2. 3. 4. 5. 6. 7. 8. Total Part IV Expenses (include in �ox C) 9503P (2013/11) + $ + $ + $ + $ + $ + $ + $ + $ � _ $ �� _ $ _ $ Page 7 of 8 , . ,, . �4uditor's Report Municipal Elections Act, 1996 �Sec#ion 78j . ' ` A candidate who has received contributions or incurred expenses in excess of $10,000 must attach an auditor's report. Professional Designation of Auditor Municipality Contact Information Last Name Address Suite/Unit No. � Street No. � Street Name Cify/Town Telephone No. (including area code) e�. Fax No. Province Email Address The report must be done in accordance with generally accepted auditing standards and must: Date (yyyy/mm/dd) Licence Number Postal Code • 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, 9996. Under section 88 of the Municipal Elections Act, 1996 (and despite anything in the Municipal Freedom of lnformation and Protection of Privacy Acfl documents and materials filed with or prepared by the clerk or any other election official under the IVlunicipal Elections Act, 1996 are public records and, until 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. 9503P (2013/11) Page 8 of 8