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. raj <br /> 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) I -201q I o>? I f 3 I to I 20/Y I /C7 L q <br /> ❑ Primary 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 45`h 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 /> re- <br /> Name of office for which the candidate sought election Ward name or no. (if any) <br /> LJ� 01^C, I or* _---- <br /> Name of Municipality <br /> Spending limit issued by clerk <br /> $ III ) is-0. gS,__ <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: Declaration <br /> I, �le fZk '0-0 taS e a candidate in the municipality of <br /> 'K xr.ti Sv--1,t hereby declare that to the best of my knowledge and belief that these <br /> financial statements Ad attached supporting schedules are true and correct. <br /> Declared before(clerk or commissioner) <br /> in the `� �-�� �> f%r•��>Sy'®�<< <br /> on(yyyy/mm/dd) <br /> Signature of Clerk or Commissioner Signature of Candidate <br /> OW5- e-J" Z)9 <br /> Date Filed in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013/11) ©Queen's Printer for Ontario,2013 Disponible en franrais Page 1 of 8 <br />
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