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Candidate - Form 4
Municipal Elections Act, /0QG(Section O8.25)
Instructions
All candidates must complete Boxes Aand B. Candidates who receive contributions or incur expenses must complete Boxes C, D,
Schedule and Schedule 2 as appropriate. Candidates who receive contributions or incur expenses in excess of $1U.00Omust also
attach anAuditor's Report.
All surplus funds (after any refund to the candidate ortheir spouse) shall be paid immediately over tuthe clerk who is responsible for the
conduct of the election.
Yvvv mw oo YvvY MM ou
For the campaign period from (day candidate filed nomination) to
�� |nihu| filing reflecting finances to December 31 (or 45 days after voting day in a by-election)
[lSupplementary filing including finances after December 81 (or 45days after voting day inaby-e|ection)
Candidate's name aoshown onthe ballot
Last Name or Single Name
Given Name(s)
CARBRAY
FLORENCE
Office for which the candidate sought election
Ward name or no. (if any)
COUNCILLOR
WARD4
Municipality
KITCHENER
Spending Limit - General
Spending Limit - Parties and Other Expressions of Appreciation
$17,126.10
$1712.61
F-1 I did not accept any contributions or incur any expenses. (Complete Boxes A and B only)
Iiqx
77777 7
|. FLORENCE CAFlBRAY
.declare that 0othe best nfmyknowledge and belief that these financial
statements and attached supporting schedules are true and correct.
raA 4141
Date Filed (yyyy/mm/dd)
Time Filed
Initial of Candidate
or Agent (if filed in person)
Signature of Clerk or Designate
Ranjeni Reddy, aCommissioner, etc.,
Province ofOntario, for the
Corporation cdthe City ofKitchener.
Expires August 27`2021.
9503P (2018/04) 0 Queen's Printer for Ontario, 2018 Disponible en frangais Page 1 of 8
LOAN
Name ufbank orrecognized lending institution BANK OF NOVA SCOTIA
Amount borrowed $
INCOME
Total amount ofall contributions (from line 1AinSchedule 1) + $ 2,28330
Revenue from items $25orless + $
Sign deposit refund + $
Revenue from fundraising events not deemed ocontribution (from Part III of
Schedule 2) + $
Interest earned bycampaign bank account + $
Other (provide full details)
1. + $
_ _
3. +$
4. +$
5. +$
Total Campaign Income (Do not include loan) = $ 2,283.36 ci
EXPENSES (Note:include the value ofcontributions n(goods and services)
Expenses subject to general spending limit
Inventory from previous campaign used in this campaign (list details in Table 4 of
$
1048.00
Schedule 1)
+
'
Advertising
+
07398
Brochures/flyers
+ o
Signs (including sign deposit)
+ $
220.35
Meetings hosted
+ $
103.69
Office expenses incurred until voting day
+ $
110.55
Phone and/or intemetexpenses incurred until voting day
+ $
Salaries, benefits, honoraria, professional fees incurred until voting day
+$
100.00
Bank charges incurred until voting day
+ $
6.95
Interest charged onloan until voting day
+ $
Other (provide full details)
1.Bank charges to Nov 30 2018
+$
13.90
2. |n8ve|
+ $
5.94
3.
+u
4.
+ $
5.
+$
Total Expenses subject to general spending limit
$
2,283.36 C2
EXPENSES
Expenses subject to spending limit for parties and other expressions of appreciation
1.
_
_
4.
5
Total Expenses subject tospending limit for parties and other expressions
of appreciation
= $
Q
9503P (2018/04) Page 2 of 8
Expenses not subject tospending limits
Accounting and audit
Cost offundraising
Office expenses incurred after,vQting day
Phone and/or internet expenses incurred after voting day
Salaries, benefits, honoraria, professioribl,fees incurred after voting day
Bank charges incurred after voting day
Interest charged on loan after voting day
Expenses related to recount
Expenses related to controverted election
Expenses related to compliance audit
Expenses related to candidate's disability (provide full details)
2
3.
4.
5.
Otho (provide full details)
'
_
3.
4
5.
Total Expenses not subject tnspending limits
Total Campaign Expenses (:2+C3+C4)
+�
Excess Neficienq0ofincome over expenses (Income minus Total Expenses)
(C1—05) + $ 0.00 D1
Eligible deficit carried forward bythe candidate from the last election
(applies to2O1Oregular election only) — $ N D%
Total (D1 —D2) $
|fthere iuoourp|uadedu�onynefun�ofoandid�e'unr
. �spouse's contributions to the campaign $
Surplus (or deficit) for the campaign = $ D3
Ifline D3shows osurplus, the amount must bepaid intrust, at the time the financial statements are filed, tothe municipal clerk who is
responsible for the conduct of the election.
9503P (2018/04) Page 3 of 8
Schedule I - Contributions
Pad|—SummarycfCuntributiune
Contributions inmoney from candidate and spouse + $ 1,235.36
Contributions ingoods and services from candidate and spouse
(include value listed inTable 3and Table 4) + $ 1,048.00
Total value o{contributions not exceeding $1OOper contributor
^
Include ticket revenue, contributions inmoney, goods and services
where the total contribution from acontributor io$1OOurless (do not
include contributions from candidate orspouna). + $
Total value of contributions exceeding $100 per contributor (from line 1 B on page 5;
list details in Table 1 and Table 2)
`
Include ticket revenue, contributions inmoney, goods and services where
the total contribution from acontributor exceeds $10O(do not include
contributions from candidate orspouae). + $
Less: Contributions returned orpayable 8othe contributor —
Contributions paid orpayable 0othe clerk, including contributions from
anonymous sources exceeding $25 — $
Total Amount of Contributions (record under Income in Box C) = $ 2,283.36 1A
Part 11 — Contributions exceeding $100 per contributor — individuals other than candidateor spouse
9503P (2018/04) Page 4 of 8
Amount $
Name
Full Address
Date Received
Amount Received $
Returned to Contributor
or Paid to Clerk
Additional information is listed on separate supplementary attachment Total
9503P (2018/04) Page 4 of 8
Table 2: Contributions in goods or services from individuals other than candidate or spouse
(Note: must also be recorded as Expenses in Box C)
Name
Full Address
Description of Goods
Date Received
Value $
or Services
(yyyy/mm/dd)
Additional information is listed on separate supplementary attachment Total
Additional information is listed on separate supplementary attachment Total
Total for Part U'Contributions exceeding *100per contributor
(Add totals from Table I and Table 2 and record the total in Part I - Summary of Contributions)
Part|U—ConthbuUonofrumcendidatenrupouee
Table 3: Contributions ingoods orservices
113
Description of Goods or Services
Date Received
Value $
Additional information is listed on separate supplementary attachment Total
9503P (2018/04) Page 5 of 8
Table 4: Inventory of campaign goods and materials from previous municipal campaign used in this campaign
(Note: value must be recorded as a contribution from the candidate and as an expense)
Description
Date Acquired
Supplier
Quantity
Current Market
2010 campaign signs
2010/08/06
Sphinx Graphics
250
1,048.00
n Additional information is listed on separate supplementary attachment Total
1,048.00
9503P (2018/04) Page 6 of 8
Schedule 2—Fundraising Events and Activities
Fund,oisingEvent/AubvitV
Complete a separate schedule for each event oractivity held
[]Additional schedule(s) attached
Description of fundraising eve activity
Date of event/activity (yyyy/mm/
Part I — Ticket revenue
Admission charge (per person)
(If there are a range of ticket prices, attach omplete breakdown of all ticket
Number of tickets sold om ete re 0
Total Part I (2A X 213) (include in Part I of Sche ule 1)
Part 11 — Other revenue deemed a contr\ibution
(e.g. revenue from goods sold in excess of fair market val e)
Provide details
2.
3.
4.
5.
Total Part II (include in Part 1 of Schedule 1)
Part III — Other revenue not deemed a contribution
(e.g. contribution of $25 or less; goods or services sold for $25 or less)
Provide details
_
3.
4.
5.
Total Part III (include under Income inBox [;
PodIV—Expeneeomlated to fundraising event uractivity
Provide details
1
_
_
4.
5.
6.
l
8.
Total Part [VExpenses (include under Expenses inBox C)
9503P (2018/04) Page 7 of 8
A candidate
Professional Desianation of Auditor
Mun
ContactDate (yyyy/mm/dd)
Last Name or Single Name Given Name(s) Licence Number
Address
Suite/Unit No. Street No. Street Name
Municipality Province Postal Code
Telephone No. (including area code) Email Address
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
F-] Report is attached
Personal information, if any, collected on this form is obtained under the authority of sections 88.25 and 95 of the Municipal Elections
Act, /000 Under section 88ufthe Municipal Elections Act, /0Q0(and despite anything inthe Municipal Freedom ofInformation 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 (2018/04) Page 8 of 8