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" C3ntario 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 DO YYYY MM DD <br /> For the campaign period from(day candidate filed nomination) to L12-4/ / 0 <br /> ✓✓ <br /> 'rPrimary filing reflecting finances to December 31 (or 45"day after voting day in a by-election) <br /> D Supplementary filing including finances after December 31 (or 45'"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 /> Nameof office for which the candidate sought election Ward name or no (if any) <br /> __ ,._ ..... .W.,. __ <br /> Name of Municipality <br /> m � <br /> Spending limit issued by clerk <br /> /7, 7s'6 - 8� <br /> 7 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 /> 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 <br /> on(yyyy/mmidd) r,20/5-- 0-314o T_ <br /> Signature of tlerk or Commissioner Signature of Candidate <br /> Date Filed in the Clerk's Office(yyyy/mmtdd) <br /> 9503P(2013111) a Queen's Printer for Ontario,2013 Disponible on trantas Pape 1 of a <br />