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Form 4
Municipal Elections Act, Y89G (Section 78)
Instructions:
All candidates must complete Boxes A and B. Candidates who receive contributions or incur expenses beyond the nomination fee
must complete Boxes C.D. Schedule 1. and Schedule 2on appropriate. Candidateawhormeiveounthbudonoovimourexpomnenin
excess of$i0.0QD must also attach an Auditor's Report.
All surplus funds (after any refund tu the candidate or his orher spouse) shall &e paid immediately over hz the clerk who was responsible
for the conduct of the election.
YYvY mm DD YvYY MM DD
For the campaign period from (day candidate filed nomination) to 2015 OL_L 27
Primary filing reflecting finances hm December 31 (or 45m day after voting day hmaby-a|eoiion)
Supplementary filing including finances after December 31 (or 4Gm day after voting day inaby-e|eotion)
Box A: Name of Candidate and Office
Candidate's name ao shown on the ballot
Last Name Given Name(s)
Nai:We—of office for which the candidate sought election Ward name or no. (if any)
Councillor Word 7
Name of Municipality
City*l'K|{ohoosr
Spending limit issued by clerk
$22,022.10
�]
I did not accept any contributions or incur any expenses other than the nomination fee. (Complete Box A and BwnAy)
Box B: Owc|ammt1sn
|. FmuziaMozbmr .a candidate in the municipality of
Kitchener .hereby declare that to the best ofmy knowledge and belief that these
financial statements and attached supporting schedules are true and correct.
V \
Declared before (clerk mcommissioner) A (Aty-, C_6:, `lJ
CkV' V--i t-�
Signature Of CIE 1. or Commissioner
Date Filed in the Clerk's Office (yyyyhmm/dd
9503P (2013/11) 0 Queen's Printer for Ontario, 2013 oisno^moemxau�ais Page 1 Of
~
Box C: Statement of Campaign Income and Expenses
LOAN
Name of bank or recognized lending institution N/A
Amount borrowed O80
INCOME
Total amount nf all contributions (From line 1Ain Schedule 1)
+ $
790200
Refund of nomination filing fee
+ $
lOO.00
Sign deposit refund
+ $
OM
Revenue from fund-raising events not deemed a contribution (From Part III of
Schedule 2)
+ $
0.80
Interest earned by campaign bank account
+ $
0.00
Other (provide full details)
1.
+ $
2.
+
3.
+ $
Total Comp�gn|ncome(0ommtincluduloan)
= $
8,002.100 C1
EXPENSES UNoto: include the value of contributions of goods and services)
Expenses subject to spending limit
Nomination filing fee
+
00
Inventory from previous campaign used in this campaign (list details inTable 5
of Schedule 1)
+
0.00
Advertising
+ $
822.410
8mohunes1flyera
+
Signs (including sign deposit)
+
3406.19
Meetings hosted
+ S
649
Office expenses incurred until voting day
+
Phone and/or Internet expenses incurred until voting day
+
Salaries, benefits, honoraria, professional fees incurred until voting day
+
Bank charges incurred until voting day
+ S
48.11
Interest charged on loan until voting day
* S
0.00
Other (provide full details)
1 ,
+
2.
+
Total Expenses subject to spending limit
=
7,098.38 C2
Expenses not subject to spending limit
Accounting and audit
+
QOO
Cost of fund-raising events/activities (list details in Part IV of Schedule 2)
+
Voting day party/appreciation notices
+
Office expenses incurred after voting day
+
Phone and!/b/ Internet expenses incurred after voting day
+
Salaries, benefits, honoraria, professional fees incurred after voting day
+
OM
Bank charges imourmdafter vobngday
_$_____
+
Interest charged om loan after voting day
+
Expenses related torecount
+
Expenses related to controverted election
+
Expenses related to compliance audit
+
Expenses related to candidate's disability (provide full details)
�
+
2.
+
3.
-----
+ �
Other (provide full details)
�
+ �
2.
+ �
3.
+ 's
Total Expenses not subject ho spending limit
851.78 C3
Total Campaign Expenses (C2*C3)
= S 79501,6 C4
9503 P (2013111) Page 2 of 8
°
Box'6: Calculation of Surplus or Deficit
Excess ofincomeaveremponmewQnoomo - Tota|Expenoaa
(Cl -C^V + $ D1
Eligible deficit carried forward by the candidate from the last election - $ 0.00 D2
Total (D1 -D2) = (48.16)
8f there is a surplus, deduct any refund of candidate's or
spouse's contributions ho the campaign - * 0.00
Surplus (or deficit) for the campaign = O3
|f line D3 shows a surplus, the amount must be paid in trust, at the time the financial statements are filed, to the municipal clerk who was
responsible for the conduct of the election.
Amount of $
paid to municipal clerk in the municipality of
9503P (2013111) Page 3 of 8
°
Schedule 1-Contributions
Full Address
Part| — SummmmrycdContribuboms
Dr. Faisal Raja
Contribution from candidate (include the value of inventory listed in Table 5) +
�
Contribution from spouse +
750.00
Total value of contributions not exceeding $18O per contributor
� Include ticket revenue, contributions in money, goods and services
where the total contribution from m contributor im$iOQon less (do not
65 Max Becker Dr., Kitchener
include contributions from candidate or spouse). +
3,642.00
Total value of contributions exceeding $100 per contributor (from line 1 B; list
200.00
200.00
details in Tables 1-4)
* Include ticket revenue, contributions in money, goods and services where
Amira Sadia
the total contribution from a contributor exceeds $1OQ (do not include
200.00
contributions from candidate orapmumm). +
$ 351000
Less: Contributions edonned'or payable Vo the contributor —
000
Contributions paid or payable tothe c|edk, including contributions from
150.00
anonymous sources exceeding $10 —
008
Total Amount ofCoothbutionm (Record in Box C) =
1A
Part |h —List ofContributions from Each Single Contributor Totalling more than
*1OO
Table 1: Monetary contributions from individuals other than candidate nrspouse
Name
Full Address
Amount $
Dr. Faisal Raja
62 Forest EdgeTrail, Kitchener
750.00
Shalizad Inayat
12 Peer Drive, Guelph, ON, N I C I G9
300.00
Khalida Adeelb Khanani
65 Max Becker Dr., Kitchener
75U0
Zahid Syed
Dr. A. Farooqi Medicine Prof.
893 Phillbrook Dr., Milton, ON
450 Gatestone Blvd, Waterloo, ON
200.00
200.00
Amira Sadia
65 Max Becker Dr., Kitchener, ON
200.00
Jennifer G Ardon
532 Mayflower St, Waterloo, ON
26000
Irfana Jalal
31 Oberdan Way, Woodbridge, ON
150.00
Additional information is listed on separate supplementary attachment Total
9503P (2013/11) Page 4 of 8
Table 2: Monetary contributions from corporations or unions
Name (Legal and Carrying on
Business As)
Full Address
President or
Business
Authorized
Representative
Amount $
Waterloo Regional Labour
Council
120 Ottawa st N, Suite
203, Kitchener
300.00
E] Additional information is listed on separate supplementary attachment Total
Table 3: Contributions in goods or services from individuals other than candidate or spouse
(Note: must also be recorded as ex penses in Box C)
Name Full Address Description of Goods Value $
or Services
[—] Additional information is listed on separate supplementary attachment
Total
9503P (2013/11) Page 5 of 8
Table 4. Contributions n goods or services from corporations or unions (Note: must also be recorded as expenses in Box C
Name of Corporation
(Legal and Carrying on
Business As
Full Address
President or
Business Manager
Authorized
Representative
Description of
Goods or Services
Value $
[:] Additional information is listed on separate supplementary attachment
Total
Total Part 11 Contributions (Add Totals from Tables 1-4) (Record in Part I — Summary) 3,510.001 B
Part III — Inventory
Table 5: Inventory of Campaign Goods and Materials from Previous Campaign used in this Campaign
(Note: value must be recorded as a contribution from the candidate and as an expense)
Description Date Acquired Supplier Current Market Quantity Total Value $
� Ammilmm/firi) � � Value$
[:] Additional information is listed on separate supplementary attachment
Total
9503P (2013111) Page 6 of 8
Schedule 2 — Fundraising Events and Activities
Fundraising Event/Activity
Complete a separate schedule for each event or activity held
M Additional schedule(s) attached
Description of fundraising event/activity Fundraising Dinner
Date of event/activity (yyyy/mm/dd) 2014/10004
Part I — Ticket Revenue
Admission charge (per person)
(lif there are a range of ticket prices, attach complete breakdown of all ticket
sales) + 30.00 2A
Number of tickets sold X 16.010 2B
Total Ticket Revenue (2A x 2B) (Include in Schedule 1) = $ 480.00
Part III — Other revenue not deemed a contribution
(provide details (e.g. contributions of $10 or less; market value of goods or services sold))
1.
_. ----------- - ... ....... +
2. Rent
2.
........ .................................. .. . .... . ... . . . . ........ . .... +
. ........ . .... ......
3. .. . ...................
+
. . . .... ....
4. . ............
. . +
....
5.
+
8.
Total Part III Revenue (include in Box C)
Part IV — Expenses related to fundraising event or activity (provide details)
1. Cost of food
1 . . . .......
+
2. Rent
+ $
3.
. ........ . .... ......
. . . .... ....
+
7.
--- ------
+
---
8.
+
Total Part IV Expenses (include in Box C)
508.510
137.00
= $ 0.00
= $ 645.50
9503P (2013111) Page 7 of 8
W
Auditor's Report
Municipal Elections Act, 1996 (Section 78)
A candidate who has received contributions or incurred expenses in excess of $10,000 must attach an auditor's report.
Professional Designation of Auditor
Municipality Date (yyyy /mm /dd)
Contact Information
Name Licence Number
Last Name First Name
Address
Suite /Unit No. I Street No. Street Name
C itylTown
Province
Telephone No. (including area code) Fax No. Email Address
ext.
Postal Code
The report must be done in accordance with generally accepted auditing standards and must:
• set out the scope of the examination
• provide an opinion as to the completeness and accuracy of the financial statement and whether it is free of material
misstatement
❑ Report is attached
Personal information, if any, collected on this form is obtained under the authority of sections 78 and 95 of the Municipal Elections Act,
1996. Under section 88 of the Municipal Elections Act, 1996 (and despite anything in the Municipal Freedom of Information and
Protection of Privacy Act) documents and materials filed with or prepared by the clerk or any other election official under the Municipal
Elections Act, 1996 are public records and, until their destruction, may be inspected by any person at the clerk's office at a time when
the office is open. Campaign financial statements shall also be made available by the clerk in an electronic format free of charge upon
request.
9503P (2013/11) Page 8 of 8