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R <br /> OC�r�� Ministry of Municipal Affairs r <br /> C 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,ODO 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 ©D YYYY MM DD <br /> For the campaign period from(day candidate filed nomination) L j j _ G � / U <br /> Primary filing reflecting finances to December 31 (or 45"t`day after voting day in a by-election) <br /> Supplementary filing including finances after December 31 (or 4e 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 /> _ ... _ ... <br /> Last Name. Given Name(s) <br /> .� ... <br /> Name of office for which the candidate sought election :Ward��name or no.(If any) <br /> t.L sti C L` E <br /> Name of Municipality <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 only) <br /> Box B 'Declaration <br /> �a a candidate in the municipality of <br /> 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 them <br /> on(yyyy/mm/dd) Q� <br /> ew. <br /> Signature of Clerk or Commissioner Signature of Candida <br /> Date Filed in the Clerk's Office(yyyylmmldd} <br /> 9503P(2013/11) "m Queen's Printer for Ontario,2013 Oisponible an franp s Page t of 8 <br />
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