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Ministry of Municipal Affairs Financial Statement — Auditor's Report <br /> lt) Ontario 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) 61� Q J n, I to <br /> X 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 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 /> 5 A i\JTb 5 ,DU E L5 C)6\j � <br /> Name of office for which the candidate sought election Ward name or no. (if any) <br /> mi n`�o T2, <br /> Name of Municipality <br /> K I N G-5 LI 1 I.�J <br /> Spending limit issued by clerk <br /> 1 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 /> 1, k)E)_­ -)n 1 j Add a candidate in the municipality of <br /> K ,A!C�5 V ;t_L4r' 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 OLAJ r\ �n K I/V65 V Il GC <br /> (YYYY ) _z r, J ✓ <br /> on /mm/dd <br /> Signature erk or Commissioner Signature of Candidate <br /> Jog/)V%l5 <br /> Date Filed In the Clerks Office (yyyy/mm/dd) <br /> 9503P(2013/11) ©Queen's Printer for Ontario,2013 Disponible en frangais Page 1 of 8 <br />