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�r- Ontario Ministry of Municipal Affairs Financial Statement - Auditor's Report <br /> and Housing <br /> Form 4 <br /> Municipal Elections Act, 1996(Section 78) <br /> Instructions: <br /> All candidates must complete Boxes A and B.Candidates who receive contributions or incur expenses beyond the nomination fee <br /> must complete Boxes C, D, Schedule 1, and Schedule 2 as appropriate.Candidates who receive contributions or incur expenses in <br /> excess of$10,000 must also attach an Auditor's Report. <br /> 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 <br /> for the conduct of the election. <br /> YYYY MM DD YYYY MM DD <br /> For the campaign period from(day candidate filed nomination) 12-04 I o� I Z,5_I to Z-0 / il-o rL <br /> [Primary filing reflecting finances to December 31 (or 451h day after voting day in a by-election) <br /> ❑ Supplementary filing including finances after December 31 (or 45th day after voting day in a by-election) <br /> Box A: Name of Candidate and Office <br /> Candidate's name as shown on the ballot <br /> Last Name �Q Given Name(s) <br /> t <br /> Name of office for hich the candidate sought election Ward name or no. (if any)LA, <br /> Name of Municipality _ <br /> W 0 f= kr",r 51.E LL <br /> Spending limit issued by clerk <br /> $ m 0 , i b <br /> C'I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and B only) <br /> Box B: Declaration <br /> >✓ IZ� 3-11: b�, b a candidate in the municipality of <br /> Alj�-5 V s z--L hereby declare that to the best of my knowledge and belief that these <br /> financial statements and attached supporting schedules are true and correct. <br /> Declared before(clerk or commissioner) <br /> in the C <br /> on(yyyy/mm/dd) <br /> Signature of Clerk or Commissioner ��P�f�'� C � 'grfiture of Candidate <br /> Date Filed in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013/11) 0 Queen's Printer for Ontario,2013 Disponible an frangais Page 1 of 8 <br />
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