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Home My WebLink AboutPetit-Pas, DorotheeMinistry 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. YYYY MM DD YYYY MM DD For the campaign period from (day candidate filed nomination) 1 20 /0 ff 0to ['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 on the ballot Last Nam or Single Nam-, Given Name(s) e�� irrice Tor wnicn the canalaate �syougnt e°1pection vvaraname or no. Municipality Spending Limit - C Spending Limit - Parties and Other Expressions of Appreciation I did not accept any contributions or incur any expenses. (Complete Boxes A and B only) Box Bs Declaration Vc ® 7-- s- statements and attached supporting schedules are true and correct. , declare that to the best of my knowledge and belief that these financial Date Filed (yyyy/mm/dd) of Date (yyyy/mm/dd) Time Filed Initial o date or Agent (if filed in person) Signature of Clerk r Designate 9'50C,'M 9503P (2018/04) Q Queen's Printer for Ontario, 2018 Disponible en frangais Page 1 of 8 l C. Statement of Campaign t eeime and Expenses . l_oA N u, Name of bank or recognized lending institution Amount borrowed INCOME Total amount of all contributions (from line 1A in Schedule 1) + $ Revenue from items $25 or less + $ Sign deposit refund + $ .. Revenue from fundraising events not deemed a contribution (from Part III of $ Schedule 2) + --.— Interest . —Interest earned by campaign bank account $ Other (provide full details) 1 + $ Z $ B,; + $ ale + $ 5.. $ Total Campaign Income me (Do not include loan) = $ 'l EXPENSES (Note: include the value of contributions of goods and services) + $ .2W Expenses subject to general spending limit +$ Inventory from previous campaign used in this campaign (list details in Table 4 of + $ $ Schedule 1) + ..mm... Advertising + $ Brochures/flyers + $ Signs (including sign deposit) + $ Meetings hosted + $ Office expenses incurred until voting day + $ Phone and/or internet expenses incurred until voting day + $ . mmm Salaries, benefits, honoraria, professional fees incurred until voting day + T Bank charges incurred until voting day + $ Interest charged on loan until voting day + $ Other (provide full details) 1, + $ .2W + $ +$ 4. + $ 5;,mmm... + $ Total Expenses subject to general spending limit $ C2 EXPENSES Expenses subject to spending limit for parties and other expressions of appreciation "t +$ 2, +$ +$ 4. + $ w ,.. mmm.mm...� + $ ... t to spending limit for parties and other expressions Total Expenses subject of appreciation $ C 9503P (2018/04) 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 + $............... Salaries, benefits, honoraria, professional 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) 1. + $ 2, + $ 5 +$ 8. + $ Other (provide full details) Total Campaign Expenses (C2 + C3 + C4) Box D: Calleviation of Surplus or Deftit W Excess (deficiency) of income over expenses (Income minus Total Expenses) (Cl — C5) + $ DI Eligible deficit carried forward by the candidate from the last election (applies to 2018 regular election only) — $ D2 Total (Q1 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 is responsible for the conduct of the election. 9503P (2018/04) Page 3 of 8 2 ib $ 3 +$ 5 + $ Total Expenses not subject to spending limits $ D4 Total Campaign Expenses (C2 + C3 + C4) Box D: Calleviation of Surplus or Deftit W Excess (deficiency) of income over expenses (Income minus Total Expenses) (Cl — C5) + $ DI Eligible deficit carried forward by the candidate from the last election (applies to 2018 regular election only) — $ D2 Total (Q1 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 is responsible for the conduct of the election. 9503P (2018/04) Page 3 of 8 Schedule 1 , Contributions Part I — Summary of Contributions Contributions in money from candidate and spouse mm m. 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); 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). + Less: Contributions returned or payable to the contributor — Contributions paid or payable to the clerk, including contributions from anonymous sources exceeding $25 — Total Amount of Contributions (record under Income in Box C) Part II — 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 F] Additional information is listed on separate supplementary attachment Amount $ Date Received Amount Received $ Returned to Contributor �or Paid to Clerk Total 9503P (2018!04) Page 4 of 8 Table �: Contributions in goods or services from individuals other than candidate or spouse (Note: must also be recorded as Expenses in Box C) Name FullAddress Description of Goods or Services 0 Additional information is listed on separate supplementary attachment )ate Received Value $ (yyyy/mm/dd) 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) Part III — Contributions from candidate or spouse Table 3: Contributions in goods or services Total $ 1� [] Additional information is listed on separate supplementary attachment 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 (yyyy/mm/dd) E Additional information is listed on separate supplementary attachment Total Current Market Value $ 9503P (2018/04) Page 6 4f 8 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) Number of tickets sold Total Part I (2A X 2B) (include in Part 1 of Schedule 1) Part II — Other revenue deemed a contribution (e.g, revenue from goods sold in excess of fair market value) Provide details 1 2. Total Part II (include in Part 1 of Schedule 1) X 0 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 1 + $ 2, + $ 1 + $ ,5. + $ Total Part Ilii (include under Income in Box C) Part IV — Expenses related to fundraising event or activity Provide details 1, 2. �....... * ....�........ mm.......mm, 5 , . 7. Total Part IV Expenses (include under Expenses in Box C) 2A 28 M 9503P (2018/04) Page 7 of 8 Auditor's 'Repo Munino al 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 Contact Information or Sinqle Name Address Suite/Unit No, Street No. Street Name Municipality Telephone No. (including area ail Address The report must be done in accordance with generally accepted auditing standards and must., Date (yyyy/mm/dd) Licence Number Postal Code 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 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) Page 8 of 8