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t," Ministry of Municipal Affairs Financial Statement - Auditor's <br /> Ontario and Housing 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) �-z p j � 0f 7 / to p Z 0 / y /O � 7 <br /> ❑ Primary filing reflecting finances to December 31 (or 45 day after voting day in a by- election) <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 /> Candidate's s shown on the ballot - -- -- - <br /> Last Nam � �°� �� Given �Ir e(sy' r /Y <br /> Name of office for which the candidate sought election Ward name or no. (if any) <br /> C 0 t(IIJC & L . . 04 <br /> Name of Municipality <br /> h' 11 r 6 S v >t_Le <br /> Spending limit issued by clerk <br /> ❑ I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and B only) <br /> Box B: DecWration <br /> 1, a candidate in the municipality of <br /> r y declare that to the best of my know dge and belief that these <br /> financial statements and attache s pporting schedules are true and correct. <br /> t <br /> Declared befor Clerk or commissioner) <br /> in the <br /> on (yyyy /mm d) t✓ `t Z <br /> Signature of Clerk or Commissioner �> y� Lr`nK Sig ture of Candidate <br /> Date Filed in the Clerk's Office (yyyy /mm /dd) <br /> 9503P (2013/11) ® Queen's Printer for Ontario, 2013 Disponible en frangais Page 1 of 8 <br />
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