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Form 4
Municipal Elections Act, /096 (Section 7D)
Instructions*
Ali candidates must complete Boxes Aand B. Candidates who receive contributions or incur expenses beyond the nomination fee
must complete Boxes C.0. Schedule 1.and Schedule 2amappropriate. Candidates who receive contributions or incur expenses in
excess of$1O,8O0 must also attach, oo Auditor's Report,
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
for the conduct of the election.
YrYv MM oo YvYY mm om
For the campaign period from (day candidate filed nomination) to
Primary filing reflecting finances tn December 31 (or 45m day after voting day inaby'e|ecMum)
[\Supplementary filing including finances after December 31 (or 4Sm day after voting day inuby-e|ect|on)
Box A/ Name wP Candidate and Office
Candidate's name as shown on the ballot
Last Name Given Name(s)
McKlusky Douglas
Name of office for which the candidate sought election Ward name or no. (if any)
WRIDS13 Public, School Trustee
Name mfMunicipality
Kitchener
Spending limit issued by clerk
$ 94^842.7O
[:] | did not accept any oom{Mbudumm or incur any expenses other than the nomination fee. (Complete Box and uo0j
Box B: Declaration
L Douglas MeKlusky .m candidate in the monicipaAdpuf
Kitchener .hereby declare that tu the best ufmy knowledge and belief that these
financial statements and attached supporting schedules are true and correct.
Declared before (clerk or commissioner) V_Y i
Signature of ClerA or Commissioner
20 14/11125
Date Filed in the ClerWs Office (yyyylmm/d,d)
9503P (2013/11) 0 Queen's Printer for Onlario, 2013 Disponible an frangais Page I of 8
Box C: Statement of Campaign Income and Expenses
Name of bank urrecognized lending institution
Amount borrowed $
INCOME
Total amount of all contributions (From line iAim Schedule 1)
Refund uf nomination filing fee
Sign deposit refund
Revenue from fund-raising events not deemed a contribution (From Part III of
Schedule 2)
Interest earned by campaign bank account
Other (provide full details)
-
2.
3.
Total Campaign Income (Do not include loan)
EXPENSES (Mmte: include, the value of contributions of goods and services)
Expenses subject to spending limit
Nomination, filing fee
Inventory from previous campaign used in this campaign (list details im Table 5
of Schedule 1)
Advertising
Brochures/flyers
Signs (including sign deposit)
Meetings hosted
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
Interest charged on loan until voting day
Other (provide full details)
t
2
3.
Total Expenses subject to spending limit
Expenses not subject to spending limit
Accounting and audit
Cost uf fund-raising events/activities (list details in Part |vofSchedule 2)
Voting day party/appreciation notices
Office expenses incurred after voting day
Phone and/or Internet expenses 'incurred after voting day
Sa|mhes, benefims, honnraha, professional fees |eoumod after voting day
Bank charges incurred after voting day
Interest charged on loan after voting day
Expenses related tnrecount
Expenses related to controverted election
Expenses related to compliance audit
Expenses related m candidate's disability (provide full details)
1
_
_
Other (provide full details)
'
_
1
Total Expenses not subject mm spending limit
Total Campaign Expenses (C2+C3)
9503P (2013/11)
+$ —3 504 26
*$
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+�
+�
+�
+�
= $ 3,604.26 C1
+ $ l00��O
=$ 3,604.26 C4
Page 2 of 8
+
+$
1 006,32
*$
+�
+$
+�
*�
+$
+�
*�
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= $
3.304.20C2
=$ 3,604.26 C4
Page 2 of 8
Box D: Calculation of Surplus or Deficit
Excess (deficiency) of income over expenses (Income — Total Expenses)
(Cl - ca) + $ 0.00 DII
Eligible deficit carried forward by the candidate from the last election — $ D2
Total (D1 -- D2) - $
If there is a surplus, deduct any refund of candidate's or
spouse's contributions to the campaign — $
Surplus (or deficit) for the campaign = $ D3
If 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
Part I — Summary of Contributions
Contribution from candidate (include the value of inventory listed in Table 5) + $ 2,559.26
Cont6bution from spouse + $ —
Total value of contributions not exceeding $100 per contributor
• Include ticket revenue, contributions in money, goods and services
where the total contribution from a contributor is $100 or less (do not
include contributions from candidate or spouse). + $ --- 40M
Total value of contributions exceeding $100 per contributor (from line I B; list details
in Tables 1 — 4)
• Include ticket revenue, contributions in money, goods and services where
the total contribution from a contributor exceeds $100 (do not include
contributions from candidate or spouse).
Less. Contributions returned or payable to the contributor
Contributions paid or payable to the clerk, including contributions from
anonymous sources exceeding $10
Total Amount of Contributions (Record In Box C)
+ $ 915,00
3,514.26 1A
Part 11 — List of Contributions from Each Single Contributor Totalling more than $100
9503P (2013/11) Page 4 of 8
T k! 1- KA^na#nn# rnnfrihtifi,nne- frnm ennanratinnn or unions
Name (Legal and Carrying on
Business As)
Full Address
President or
Business Manager
Authorized
Representative
Amount $
Waterloo Regioll LabOUr
C"Ouncil
203-120 Ottawa St N
Kitchener Ont
Marc Xuereb
March Xuereb
40.00
OS I" District 24
vo]" Bargaining Unit_
225 Cenniennial Crt
Kitchener Ont
Sherry FrUend
Sherry Fruend
25U0
C. District 24
Political Action Conini.
275 cell nwn n ial -Crt I
Kitchener Ont
Sherry FrUetid
Sherry l7ruend
150.00
OSSTF
225 Cenntennial Crt
Kitchener Ont
Dianne Flewwelling
Dianne Flewwelling
-Hutcheson
250.00
Waterloo Region
Together in Education
610 Wabanaki Dr
Kitchener Ont
Nancy [16i-cheson
Nancy
100.00
EFTO Waterloo
610 Tabanaki Dr
Kitchener Ont
Nancy Hutcheson
Nan cy I lutcheson,
125.00
F] Additional information is listed on separate supplementary attachment To,;]
Table 3: Contributions in goods or services from individuals other than candidate or spouse
9503P (2013111) Page 5 of 8
Tnhlm A• nnnrrih,itinnc in rpDiDds or sprvir_es 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 II Contributions (Add Totals from Tables 1-4) (Record in Part I - Summary) $ 1 B
Part III - Inventory
Table 3: 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 $
{yyyylmmldd} I 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
❑ Additional schedule(s) attached
Description of fundraising event/activity
Date of eventlactivity (yyyylmmldd)
Part I - Ticket Revenue
Admission charge (per person)
(if there are a range of ticket prices, attach complete breakdown of all ticket
sales)
+
$ 2A
Number of tickets sold
x
2B
Total Ticket Revenue (2A X 26) (Include in Schedule 1)
_ $
Part It - Other revenue deemed a contribution
(provide details (e.g. revenue from goods sold in excess of fair market value))
1
+
$
2
+
$
3
+
$
4.
+
$
5
+
$
Total Part II Revenue (include in Schedule 1)
_ $
Part III -- Other revenue not deemed a contribution
(provide details (e.g. contributions of $14 or less; market value of goods or services sold))
1.
+
$
2
+
$
3.
+
$
4.
+
$
5.
+
$
Total Part III Revenue (include in Box C)
- $
Part IV - Expenses related to fundraising event or activity (provide details)
1.
+
$
2.
+
$
3.
+
$
4.
+
$
5
+
$
6.
+
$
7
+
$
8
+
$
Total Part IV Expenses jinclude in Box C)
= $
9503P (2013!11)
Page 7 of 8
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 (yyyylmmldd)
Contact Information
Last Name First Name Licence Number
Address
Suite /Unit No. Street No. Street Name
City/Town Province Postal Code
Telephone No. (including area code) Fax No. Email Address
ext.
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
9996. Under section 88 of the Municipal Electrons Act, 1996 (and despite anything in the Municipal Freedom of Information and
Protection of Privacy Act) documents and materials fled 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 (2013111) Page 8 of 8