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yr" Ontario Ministry of Municipal Affairs Financial Statement - Auditor' <br /> and Housing s 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. YYYY MM DD For the campaign period from(day candidate filed nomination) I �i(,� I o �f I f 3 Ito `� �YYYY � DD <br /> 1 '7 <br /> j 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 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 <br /> Given Name(s) <br /> Name of office for which the candidate sought election Ward name or no. (if any) <br /> Name of Municipality <br /> Spending limit Issued by clerk <br /> $ /,-7 <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 /> a candidate in the municipality of <br /> 'C lili�t.— 4 Z°�-��" Cee 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 the - OWA' QEC/� ��ILL x,11 1 r�1 <br /> on (yyyy/mm/dd d F d f S <br /> Signatur of Clerk or Commissioner Sig ur of C didat <br /> e 3 1,04 <br /> Date Fil in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013/11) ®Queen's Printer for Ontario,2013 Disponible en frangais <br /> Page 1 of 8 <br />