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yr" Ontario Ministry of Municipal Affairs t ' <br /> Financial Statement - Auditors Re <br /> and Housing port <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 at C i i I C,4 to <br /> D' rimary 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 451h 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 /> Name of office for which the candidate sought election Ward name or nb. (if any) <br /> , . ry <br /> Name of Munnnici ality <br /> V-,If y 1 C Gy^h � <br /> Spending limit isslied by clerk <br /> 75 61 Y- <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 /> hereby declare that to the best of my knowledge and belief that these <br /> financial stateme is and attached supporting schedules are true and correct. <br /> Declared before(clerk or commissioner) <br /> in the -Iit,�V v <br /> on(YYYY/mm/dd) .2B/L14 <br /> Signature of Clerk or Commissioner Signature of Can i a e <br /> Date Filed in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013/11) ®Queen's Printer for Ontario,2013 Disponible en franeais <br /> Page 1 of 8 <br />