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J <br /> l- Ontario Ministry of Municipal Affairs Financial Statement - <br /> and Housing Auditor's Report <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) I �/�/ 10/ I 4.1 I to ©/ 0 <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) <br /> 2:_,4,A!V <br /> 66r- <br /> Name of office for which the candidate sought election Ward name or'no. (if any) <br /> ("IU uA <br /> Name of Municipality <br /> R <br /> Spending limit issued by clerk <br /> - <br /> $ LZ 7,5-a .6< <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 /> 1. %D�✓Y���'�� <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) rf'p- <br /> inthe rwt,, of -C%*r,4 SJ,* t�e/ t/\ <br /> on(YYYY/mmldd) U41 <br /> 0f- �SSex or�J <br /> `�ovt?imbCA to <br /> �P u4y-(AejL. Signature of Clerk or Commissioner <br /> �'Ot.Vflc.t( cSef _;0 v'�cc5 m1 � 1 ' gnat r o Candidate <br /> 2 <br /> Date Filed In the Clerk's Office(yyyy/mm/dd) <br /> 9503P(2013/11) ®Queen's Printer for Ontario,2013 Disponible en franFais <br /> Page 1 of 8 <br />
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