Box B: Summary of Campaign Income and Expenses

1. My spending limit (as issued by clerk) was

2. Surplus (or deficit) from previous election

3. Total contributions received (from Schedul 1)

4. My total campaign expenses that were subject to the spending limit were (from Box C) - -

5. My total campaign expenses that were not subject to the spending limit were (from Box C) - -

6. Total of all campaign expenses (from Box C)

7. Election campaign surplus/deficit from current election (from Box E)

8. Contributions refunded to candidate or spouse (from Box E)

9. Amount paid to clerk (from Box E)

t’>Ontario Ministry of Municipal Affairsand Housing Financial Statement — Auditor’s Report

Form 4Municipal Elections Act, 1996 (Section 78)

Instructions

All candidates must complete Boxes A, B, C, D, E and F and Schedule 1. All candidates must complete Schedules 2, 3 and 4 asappropriate. 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 his or her spouse) shall be paid immediately over to the clerk who was responsiblefor the conduct of the election.

YYYY MM DD YYYY MM DD

For the campaign period from (day candidate filed nomination) O 9 I O to OI I . 3 I

ary filing reflecting finances to December 31 (or 45th day after voting day in a by-election)

Supplementary filing including finances after December 31 (or 45th day after voting day in a by-election)

Box A: Name of Candidate and OfficeName of Candidate

Last Name - First Name Middle Initial

.‘ LôMailing Address

Suite/Unit No. Street No. Street Namecl

City/Town Province Postal Code

oCO iLLsTelephone No. (md. area code) .- Fax No. Email AddressBusiness Home

Co Sq z n-z j.eJ LLL,S m&L. CU1T

Name of office for which the candidate sought election Ward l!’ame or No. (if any)

CôjName of Municipality

CJft Ue

$ Io1-S.S’S

$t-/

$ 4C).\-

$ 0C

$ C\ C 4

$L5

$

9503P (2010/01) © Queen’s Printerfor Ontario, 2010 Disponible en francais Page 1 of 8

3.

Other (provide full’details)

1. C\ô;.

$ O-

S

1.

$

2.

3.

$ O

$$L

=I$ id

$

$$ 0.00

Box C: Statement of Campaign Period Income and Expenses

From To For CandidateMM DD MM DD k

INCOME

_______

Candidates surplus from immediately preceding election released by the clerk + $ 6” b

Contributions from candidate +

Contributions from spouse of candidate +

All other contributions +

Revenue from fund-raising functions not deemed a contribution(ñom Schedule 2, Part Ill) ÷

__________________

Interest income +

Other (provide full details)

_____________________

+

+

+

Total Campaign Period Income

EXPENSES (Note: include the value of contributions of goods and services)

Expenses Subject to Spending Limit

Advertising +

Bank charges +

Brochures +

Interest on loan +

Inventory contributed to candidate’s campaign (Schedule 3) - - - - - -‘ +

Meetings hosted +

Nomination filing fee +

Office expenses +

Phone and/or Internet +

Salaries and bnefits/honoraria/professional fees +

Signs-

+

Other (provide full details)

1.Lt-\ c:b +

2. Ex* -k\c A c ÷

________

ac ccrs +

__________

Subtotal =

Expenses Not Subject to Spending Limit

Accounting and audit +

Costs of fund-raising function (from Schedule 2, Part IV) +

Expenses related to compliance audit ÷

Expenses related to controverted elections +

Expenses related to recounts +

Voting day party / appreciation notices +

Expenses related to candidate’s disability (provide details) i—i 1 k1. Ccrn 1k& c*j2. Jr4-Vte -d¶*o +

+

+

+

+—I

Subtotal =

Total Campaign Period Expenses (C2) + (C3)

Excess (Deficiency) of Income over Expenses (Cl) — (C4)

$ 4O3L1cSO.$ icc’’$ çSS

$.$

‘L lzci5(,

C2

________________

C3

=$+(pLO+ C4

= $ o.°q

$

$ 4L4.

$ .

$ L4cO .4

$$-

S &

$ 1c-scD’

$$$ (D2

3. Accc‘ -

$ 4.lO

$$32 qc(

$ °

9503P (2010/01) Page 2 of 8

Box D: Statement of Assets and Liabilities as at 20

Assets

Cash +

Accounts receivable +

Value of inventory retained (from Schedule 4) +

Other (provide full details)

1. - p.vs +-.y.

2.

3.

Total Assets

Liabilities and Excess (Deficiency) of Income over Expenses

Accounts payable

Borrowings, overdraft

Other (provide full details)

+

+

+

+

1.

2.

3.

+

+

+

Total Liabilities

$ •:f1 lt:3

$ --- \D%:e—

$ 0‘4’

$‘c

$ o.t

$s$ C) -

= Is (r

Box E: Statement of Determination of Surplus or Deficit and Disposition of Surplus

Part I — Determination of Surplus or Deficit

__________________

Amount of excess (deficiency) of income over expenses (from Box C) +

Deduct: Any deficit carried forward by the candidate from immediately preceding electionif the offices are with respect to the same jurisdiction —

Surplus (or deficit) for the campaign period (El) — (E2) =

Deduct: Any refund of contributions to the candidate or spouse (only if there is a surplus) —

TotalDetermination . =

Part II — Disposition of Surplus

If line E3 shows a surplus, the amount must be paid in trust, at the time the financial statements are filed, to the municipal clerk who wasresponsible for the conduct of the election.

Surplus paid to the municipal clerk of the municipality of

Box F: Declaration

i_JL 4L , a candidate in the municipality of

(—ltj ç- (jrjc..c,jAe_. hereby declare that to the best of my knowledge and belief that these

financiaI statements and attached supporting schedules are true and correct.

:

•

__

}

________

Signatvre of Clerk or Commissioner Siliature of Candidate

,5 /r?di-e41 J

Date Filed in the Clerk’s Office (yyyy/mm/dd)

Vlckj Baker, a Commissioner, etc.

Province of Ontario, for theCorporation of the City of Brockvijle.Expires June 3, 2016.

$ •qC\

-.4,

$ cc El

$ ( cc €2

$

$ V3 ‘—

$ L( E3

Declared before (clerk or commissioner)

(J.I o’ 8h5c-kVi/)eon (yyyy/mm/dd) ãO /

I —

9503P (2010/01) Page 3of8

Schedule I — Contributions

_________ ____________

Part I — Contribution

Contribution from candidate

Contribution from spouse

Total from each single contributor totalling more than $100

• include all ticket revenue where ticket price exceeds $100

• include all goods and services where value exceeds $1 00*

• do not include contributions from candidate or spouse

Total from each single contributor totalling $100 or less

• include all ticket revenue where ticket price is $100 or less

• include all goods and services where value is $100 or less*

• do not include contributions from candidate or spouse

*Note: Goods and services must also be reported as expenses in Box C

Less; Contribution returned or payable to the contributor

Contribution paid or payable to the clerk

Total Amount of Contribution

Total contribution from anonymous sources-

Amount of contributions paid or payable to the clerk (IA) + (IB)

tkIAcLI’4chax

I__I,.’.

6m Ccb

1

+c c

__________

LLb&,

Name

$ 0,cC’

$ CjLk

$ •rR.:tc:

$ \CCU)

Part II — List of Contributions from Each Single Contributor Totalling More than $100

Table 1: Monetary contributions from individuals other than candidate or spouse

IA

lB

$

Address

cA c1cri-c. CD FLC, Rcre t\Ke n \ p $ JAmount

I\r $ 1

b b-O$

e-4_)____ ‘_)

1c 3 wôoó Sps Aac\ $ ô

TC1 c3cr jôe. Seà% $

8-x c’rsor . S&oed 4M $ 10$

Ps +\$ - ‘ LcS $ Co

5 z5c2 ktEe Ork- L (d- S

c. e. O toE(o

- 2Li.cS Paó it -bCke- 37 $ 5oL81 cLx’c CA. 1 (S

$ 5Y

U

g’i:aLr

Its eôn.

$

kLi eb\ 1- &e.& <fJL4(1 $

Pit.x odje.S

5r 9 ‘ S -

The&ce Loe- &o c-s1e $ .ê

q- ea. $

( Ieo p&C &c€ek *-trb 3T (o $t t\ \ ,. ‘

-.- j

LLI J cO

$-\ J MS $

c5ce s’ WqM $

ditional information is listed on separate supplementary attachment‘

Total

t: tJL

$

9503P (2010/01) Page 4 of 8

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Lchedule 3 — Inventory of Campaign Goods and Materials (from Previous Campaign)

Used in Candidate’s Campaign

Schedule 4— Inventory of Campaign Goods and Materials at The End of Campaign

Description Date Acquired Supplier Unit Value Quantity Total Value

(yyyylmmldd)

L3s $ 5O 3+S’oo1c\ Lurc3 $ 1L)Q $

$ $

$ $

$ $

$ $

$ $

S $

$ $

$ $

$ $

Total Value of Inventory of Campaign Goods and Materials

9503P (2010/01)

$

Total Value of Inventory from Previous Campaign Used in Candidate’s Campaign

Page 7 of 8