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d <br /> 1 <br /> ' raj <br /> i t Ontario MInIMou r^ 9unicipal Affairs Financial Statement -Auditor's Report <br /> Form 4 <br /> Municipal Electrons 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) a L4 I to ) / <br /> (�Primary filing reflecting finances to December 31 (or 45h day after voting day in a by-election) <br /> 0 Supplementary filing including finances after December 31 (or 451"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) d <br /> Name of office for which the candidate sought election Ward name or no.(if any) <br /> Name of Municipality <br /> 6-16b'111e <br /> Spending limit issued by clerk <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 /> � � C' ti�/ a candidate in the municipality of <br /> / n G E c r Ile-` /7 <br /> e 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 i��u� OF �if� � �/C_LC r <br /> on(yyyylmmidd) <br /> Signature of Clerk or Commissioner Signa of Candidate <br /> Ic <br /> )v J�- C 3 <br /> Date Filed in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013111) 0 Queen's Printer for Ontario,2013 Disponible an franpals Page 1 of 8 <br />
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