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�l- Ontario Ministry of Municipal Affairs Financial Statement - Auditor's Report <br /> and Housing p <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 /> ;7pria campaign period from(day candidate filed nomination) 4)i 05 i — I to I aQ q o I o <br /> mary filing reflecting finances to December 31 (or 45th 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 Given Name(s) <br /> K)(-ckv )K G eu r e, M <br /> Name of office for which the candidate sought election Ward name or n . (if any) <br /> C 0\.kn c \�\0�- <br /> Name of Municipality <br /> K;,AGS�,11e , <br /> Spending,, it issued by clerk <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 /> I, ©r f a v I ^ a candidate in the municipality of <br /> hereby declare that to the best of my knowledge and belief that these <br /> financial st.4ements and attached supporting schedules are true and correct. <br /> Declared before(clerk or commissioner) <br /> in the LO ,�s rf\, s j <br /> on(yyyy/mm/dd) Coj!1 0� SS Gn <br /> Signature of Clerk or Commissioner G <br /> C (P r t� C'�'�"I ����` Signature of Candida e <br /> . 0 t CZ <br /> Date Filed in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013111) ©Queen's Printer for Ontario,2013 Disponible an frangais Page 1 of 8 <br />