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R � <br /> t r - Ministry of Municipal Affairs Financial Statement - ' <br /> Ontario and Housing Auditor s Report <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) 1 1 7 D I r 2 0141 la - 3 0 <br /> Primary filing reflecting finances to December 31 (or 45 day after voting day in a by- election) cam ! 7 I t 1 7 <br /> ❑ Supplementary filing including finances after December 31 (or 45 day after voting day in a by- election) <br /> Box A: Name of Candidate and Office <br /> C andidate's name as shown on the ballot -- --- - - - - -- <br /> Last Name Given Name(s) <br /> L D ` T / A/ 13 C XA/ %L' <br /> Name of office for which the candidate sought election Ward name or no. (if any) <br /> Al O <br /> Name of Municipality <br /> KIA/a S V,1 L z_ ° <br /> Spending limit issued by clerk <br /> $ /I, 7s . 9� <br /> 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 /> a candidate in the municipality of <br /> /4 51 -6 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 <br /> on (yyyy /mm /dd) <br /> Signature of Clerk or Commissioner gignature of Candidate <br /> � "i'J o 3 l <br /> Date Filed in the Clerk's Office (yyyy /mm /dd) <br /> 9503P (2013/11) 0 Queen's Printer for Ontario, 2013 Disponible en frangais Page 1 of 8 <br />
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