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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 YYYY MM DD <br /> For the campaign period from(day candidate filed nomination) 14,i e/t, I ey�I/f�I to , y <br /> [-f-rimary 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 45`h 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 /> Name office for which the candidate sought election Ward name or no. (if any) <br /> Name f Municipality <br /> Spending frmit issued by clerk <br /> I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and 8 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 /> financials tements and attached supporting schedules are true and correct. <br /> Declared before'(clerk or commissioner) <br /> in the 147,1,OAI ��a��/�✓�S!/7�L� <br /> on(yyyy/mm/dd) ,2615-1& 1164 <br /> �rSignature o Clerk or Commissioner"Pf , ? Zi_ekle re of Candidate <br /> Date Filed in the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013111) ®Queen's Printer for Ontario,2013 Disponible en franpais <br /> Page 1 of 8 <br />