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Ontario Ministry of Municipal Affairs Financial Statement - Auditor's Report <br /> and Housing p rt <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 <br /> For the campaign period from(day candidate filed nomination) xo1 y I of Io; to YYYY I 1 Z I S DD <br /> � � I I ,��/� <br /> 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 Given Name(s)Gs <br /> Name of office for which the candidate sought election Ward name or no. (if any) <br /> Name of Municipality <br /> _ K111 ;/l IL <br /> Spending I It Issued by clerk <br /> $ 1, : _760. 6S <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 /> l Qitit ' "t f� a candidate in the municipality of <br /> �Ac S✓dl 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 .—<.—J ��,� / <br /> on(yyyy/mm/dds) <br /> Signature of Clerk or Commissioner Signatu of ndidate <br /> Ui S <br /> Date Filed in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013/11) O Queen's Printer for Ontario,2013 Disponible en franFais <br /> Page 1 of 8 <br />
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