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Home My WebLink AboutDomagala, Hanna Monika�"- Ministry of Municipal Affairs Financial Statement Auditor's Report Ontario Candidate - Form 4 Municipal Elections Act, 1996 (Section 88.25) Instructions All candidates must complete Boxes A and B. Candidates who receive contributions or incur expenses must complete Boxes C, D, Schedule 1 and Schedule 2 as appropriate. Candidates who receive contributions or incur expenses in excess of $10,000 must also attach an Auditor's Report. All surplus funds (after any refund to the candidate or their spouse) shall be paid immediately over to the clerk who is responsible for the conduct of the election. to � 0 rt" MM RD For the campaign period from (day candidate filed nomination) 2 p 1 8 0 7 '12 7 2 0 1 8 1 1 21 3 1 ] fl Initial filing reflecting finances to December 31 (or 45 days after voting day in a by-election) ❑ Supplementary filing including finances after December 31 (or 45 days after voting day in a by-election) Box A: Name of Candidate and Office Candidate's name as shown _. ......__ s, ...... ....�.. on the ballot Last Name or Single Name Given Namesj Domagala Hanna Monika Office for which the candidate sought election N Councillor 7 ______.... . Municipality Kitchener Spending Li name or no. (if any) Spending Limit - $ did not accept any contributions or incur any expenses. (Complete Boxes A and B only) Box B: Declaration ation I, Hanna Dornagala - declare that to the best of my knowledge and belief that these financial statements and attached supporting schedules are true and correct. ,OM1 t Candidate 9503P (2018/04) ® Queen's Printer for Ontario, 2018 of Candidate or Aqent (if filed in person) Disponible en frangais PDF created with pdfFactory Pro trial version www.pdffactory.com Dat (YYYY/m /d d) nature.of,Clerk or Desiqnate Page 1 of 8 Box C: Statement of Campaign Income and Expenses LOAN......................... __...... ..... ......... ... .... .... .... Name of bank or recognized lending institution Amount borrowed ^� .. .. .... ........ EXPENSES (Note: include the value of contributions of goods and services) Expenses subject to general spending limit Inventory from previous campaign used in this campaign (list details in Table 4 of $ Schedule 1) Advertising..— .. .... ._.. $ 769.58 Brochures/flyers + $ 1 046.-8 6 Signs (including sign deposit) + $ 977.50 Meetings hosted + $ Office expenses incurred until voting day + ....._. $ Phone and/or Internet expenses incurred until voting day J, $ 35.1 1 Salaries, benefits, honoraria, professional fees incurred until voting day +p $ Bank charges incurred until voting day + $ 7 Interest charged on loan until voting day + $ Other (provide full details) �.................... EXPENSES Expenses subject to spending limit for parties and other expressions of appreciation 9503P (2018/04) PDF created with pdfFactory Pro trial version www. dffactor L,cor Page 2 of 8 Expenses not subject to spending limits Accounting and audit + $ Cost of fundraising events/activities (list details in Part IV of Schedule 2) + $ Office expenses incurred after voting day + $ Phone and/or internet expenses incurred after voting day N° $ Salaries, benefits, honoraria, professional fees incurred after voting day + $ Bank charges incurred after voting day + .. , . ....... $ 7.90 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) ................................................................................................... 1,+ $ ..__ .................. ........__. 2.+ _,_,..... ...... ....................--- 3.+ $ _,_,_... ,................... .. 4.+ ......... ......... ......... .... $ ....................._.. Sw+ $ Other (provide full details) t, ... + $ ...._, _._ ..._................. 2., + $ .�._.................................................................................................. _,�......., 3. + ... _............... 4. .... * $ ........... 5. , +$ ..... ....,...-----... .. ...._._.........._ ......... ........ Total Expenses not subject to spending limits = 7.90 C4 Total Campaign Expenses (C2 + C3 + C4) Box D: Calculation of Surplus or Deficit Excess (deficiency) of income over expenses (Income minus Total Expenses) (Cl — C5) + $ 0.00 DI _.......................................................................... Eligible deficit carried forward by the candidate from the last election (applies to 2018 regular election only) $ 0 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 $ 0„3; $ 2,844.85 C5 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 is responsible for the conduct of the election. 9503P (2018/04) PDF created with pdfFactory Pro trial version www,pdffactor,,co�ngl Page 3 of 8 Schedule 1 -Contributions _..... _ ......... __... ......... _............. ........... .... -- _...... ... ------ Part I — Summary of Contributions Contributions in money from candidate and spouse + $ 1,090.85 Contributions in goods and services from candidate and spouse (include value listed in Table 3 and Table 4) + '$ 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). 5 1,004.00 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 in money, goods and services where the total contribution from a contributor exceeds $100 (do not include contributions from candidate or spouse). + $ 750.00 ............................................................................................................. Less: Contributions returned or payable to the contributor S Contributions paid or payable to the clerk„ including contributions from anonymous sources exceeding $25 Total Amount of Contributions (record under Income in Box C) 5 2,844.85 1A Part It Contributions exceeding $100 per contributor — individuals other than candidate or spouse Table 1: Monetary contributions from individuals other than candidate or spouse ...... , Name Full Address Date Received � Amount Received $ omas Scott Wiggins 525 Union Street E Fergus, ON N1M 1W4 933 Pioneer Grove Kitchener, ON N2P OB2 rt Additional information is listed on separate supplementary attachment 9503P (2018/04) 2018/10/12 � 250.00 2018/10/09 I 500.00 Total 750. PDF created with pdfFactory Pro trial version www.pdffactory coma count $ turned to Contributor Paid to Clerk 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) Total for Part II - Contributions exceeding $100 per contributor (Add totals from Table 1 and Table 2 and record the total in Part 1 - Summary of Contributions) 1 750.00 1 B Part 111— Contributions from candidate or spouse Table 3: Contributions in goods or services 9503P (2018/04) Page 5 of 6 PDF created with pdfFactory Pro trial version www.pdffactorV.com Description of Goods or Services (yyyy/mm/dd) Additional information is listed on separate supplementary attachment Total Value $ 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) 9503P (2018/04) Page 6 of 8 PDF created with pdfFactory Pro trial version www.pdffactory.com Schedule 2 — Fundraising Events and Activities Fundraising Event/Activity Complete a separate schedule for each event or activity held 0 Additional schedule(s) attached Description of fundraising event/activity Date of event/activity (yyyy/mm/dd) ..._...... Part I — Ticket revenue Admission charge (per person) (If there are a range of ticket prices, attach complete breakdown of all ticket sales) 2q Number of tickets sold X 2B Total Part I (2A X 26) (include in Part 1 of Schedule 1) Part IV — Expenses related to fundraising event or activity Provide details 9503P (2018/04) Page 7 of 8 PDF created with pdfFactory Pro trial version www.pdffactorV.com Auditor's Report Municipal Elections Act, 1996 (Section 88.25) A candidate who has received contributions or incurred expenses in excess of $10,000 must attach an auditor's report. Professional Designation of Auditor Street Name The report must be done in accordance with generally accepted auditing standards and must: Date 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, 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(2018/04) PDF created with pdfFactory Pro trial version www.pdffactoi,,)Ln Page 8 of 8