CANDIDATE'S ELECTORAL CAMPAIGN RETURN[Section 477.59 of the Canada Elections Act]

EC 20120 (2016/04) Ce formulaire est disponible en français

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Declaration PART 1

SECTION A – CAMPAIGN INFORMATIONPolitical affiliation (if any)

ED code Electoral district

Date writ issued yyyy/mm/dd

SECTION B – CANDIDATE'S INFORMATIONSurname Given name Middle

initial

Street no.

Street Apt.

Primary phone number

Alternate phone number

E-mail address

SECTION C – OFFICIAL AGENT'S INFORMATIONSurname Given name Middle

initial

Street no.

Street Apt.

Primary phone number

Alternate phone number

E-mail address

SECTION E – REQUIRED DOCUMENTS (COMPLETE RETURN)

The following documents MUST accompany this return:

All Parts of the return, including parts that are nil

Auditor's Report, Checklist for Audits (EC 20011) and Auditor's Invoice

Originals of all vouchers (invoices or other supporting documents), bank statements, deposit slips, cancelled cheques, loan agreements (including all terms and conditions and repayment schedules), copies of contribution cheques and other pertinent documentsCandidate's Statement of Personal Expenses (EC 20220)

City Prov./ Terr.

Postal code

City Prov./ Terr.

Postal code

SECTION F – REQUIRED DOCUMENTS (NIL RETURN)

The following documents MUST accompany this return:

Part 1 Auditor's Report and invoice

Candidate's Statement of Personal Expenses (EC 20220) Checklist for Audits (EC 20011)

SECTION D – TYPE OF RETURN Complete Nil (No transactions)

SECTION H – DECLARATION

I hereby declare that to the best of my knowledge:

• The information contained in this return is complete and accurate.

• All expenses incurred as an incidence of the election have been properly recorded.

• No money, goods or services have been provided by way of loan, advance, deposit, contribution or gift during the electoral campaign, except as appears in this return.

• No other person or entity has, on behalf of the candidate, made any payment or given, promised or offered any reward, office, employment or valuable consideration or incurred any liability on account of or in respect of the conduct or management of the electoral campaign, except as specified in this return.

Candidate's signature

Candidate's signature date yyyy/mm/dd

Official agent's signature date yyyy/mm/dd

Official agent's signature

SECTION I – PRIVACY NOTICE

Personal information in this Candidate’s Electoral Campaign Return (Return) is collected for the administration of the political financing requirements set out in the Canada Elections Act (Act). This information may be shared with the Commissioner of Canada Elections to ensure that the Act is complied with and enforced as well as the Canada Revenue Agency in relation to the Income Tax Act. Failure to provide the Chief Electoral Officer (CEO) with the Return is considered to be an offence under the Act. Upon request by any person, the CEO is required under the Act to make the Return available for inspection by such person. You have the following rights with respect to your personal information under the Privacy Act: a) to access the information; b) to correct it, if necessary; and c) to have it protected. You have the right to file a complaint with the Privacy Commissioner of Canada regarding the handling of your personal information. Your personal information is retained under the personal information bank (PIB) Elections PPU 010. A description of the PIB can be found at www.infosource.gc.ca.

Election day yyyy/mm/dd

SECTION G – NOMINATION DEPOSIT PAID BY

Candidate Candidate's campaign

Registered party

Registered association

Other (please provide full name and address)

Other name and address:

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Contributions Received PART 2a

No. Surname Given name Middle initial

Street no. Street Apt. City Prov./

Terr. Postal code

Date

received yyyy/mm/dd

1 Monetary

$

2 Non-monetary

$

3 Total per

contributor $

Totals carried forward from previous page $

Subtotal $(A)

Total amount of monetary and non-monetary contributions of $200 or less, other than those reported in Amount C $(B)

Number of contributors of $200 or less

Total amount of anonymous contributions of $20 or less $(C)

Approximate number of anonymous contributors

Total amount of all contributions $(A+B+C)

Number of contributors

ED code Candidate's surname

Candidate's given name Page of

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CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Operating Loans PART 2b

Lender details

Type of lender: A - Individual B - Financial institution C - Registered party D - Registered association

Surname Given name Middle initial Street no. Street Apt. City Prov./

Terr.Postal code

Type of lender (A/B/C/D)

Loan details

Type of loan: A - Term B - On demand C - Line of credit D - Overdraft

Loan no. Date received yyyy/mm/dd

Type of loan (A/B/C/D)

Fixed interest rate

%

Variable interest rate (prime + or -)

%

Amount borrowed or maximum amount overdrawn

$

Principal payment(s)

$

Interest payment(s)

$

Balance as of date of return

$

Balance of loan as of December 31

Balance as of December 31 Year 1

$

Balance as of December 31 Year 2

$

Balance as of December 31 Year 3

$

Balance as of December 31 Year 4

$

Balance as of December 31 Year 5

$

Guarantor details

Date received

yyyy/mm/ddSurname Given name Middle

initial Street no. Street Apt. City Prov./ Terr.

Postal code

Type of guarantor (A/B/C)

Amount guaranteed

$

Total amount guaranteed $

Number of guarantors

Page ofED code Candidate's

surnameCandidate's given name

Type of guarantor: A - Individual B - Registered party C - Registered association

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Contributions Returned to Contributors or Remitted to the Chief Electoral Officer PART 2c

No. Date

received yyyy/mm/dd

Surname Given name Middle initial

Street no. Street Apt. City Prov./

Terr.Postal code

Type of contributor

(A or B)

Monetary

$

Non-

monetary

$

Date returned to contributor yyyy/mm/dd

Date remitted to

CEO yyyy/mm/dd

Totals carried forward from previous page $

Total $

Type of contributor: A - Individual B - Other

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

PART 2dCANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Transfers Received

No.Date

received yyyy/mm/dd

ED code of transferor Name of political entity making transfer

Registered party

Monetary

$

Registered party Non-monetary

$

Registered association Monetary

$

Registered association

Non-monetary $

Nomination contestant Monetary

$

Totals carried forward from previous page $

Total $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Cash Inflows Other Than Contributions, Loans and Transfers PART 2e

No.Date

received yyyy/mm/dd

Source and details

1 Non-contribution

portion of ticketed fundraising revenues

$

2

Bank interest

$

3

Refunds from suppliers

$

4

Returned portion of advances

$

5

Proceeds from sale of assets

$

6

Other

$

Totals carried forward from previous page $

Total $

Grand total (columns 1 to 6) $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

PART 2fCANDIDATE'S ELECTORAL CAMPAIGN RETURN Summary of Contributions, Loans, Transfers and Other Cash Inflows

No. Type of inflow

1

Monetary

$

2

Non-monetary

$

3

Total (1+2)

$

4

Number of contributors or

lenders

CONTRIBUTIONS

1. Individuals

LOANS - Not including overdraft(s)

2. Individuals

3. Financial institutions

4. Registered party

5. Registered associations

6. Subtotal loans (items 2 to 5)

TRANSFERS

7. Registered party

8. Registered associations

9. Nomination contestants

10. Subtotal transfers (items 7 to 9)

OTHER

11. Other cash inflows

TOTAL

12. Total (1 + 6 + 10 + 11)

ED code Candidate's surname

Candidate's given name

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Electoral Campaign Expenses and Other Outflows PART 3a

No. Date yyyy/mm/dd

Supplier Cheque no.

Amount paid

$

Contributed or

transferred property or

service $

Unpaid claim

$

1 Election

expenses subject to the limit

$

2

Candidate's personal expenses

$

3 Other

expenses and

outflows $

Totals carried forward from previous page $

Total $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Election Expenses Subject to the Limit, from Part 3a, Column 1 PART 3b

No. Date yyyy/mm/dd

Supplier Description Cheque no.

Amount paid

$

Contributed or

transferred property or

service $

Unpaid claim

$

1

Advertising

$

2

Voter contact calling

services $

3

Office

$

4

Salaries and wages

$

5

Other

$

Totals carried forward from previous page $

Total $

Grand total (expenses subject to the limit - columns 1 to 5) $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

PART 3cCANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Candidate's Personal Expenses, from Part 3a, Column 2

No. Date yyyy/mm/dd

Supplier Description Cheque no.

Amount paid

$

Contributed or

transferred property or

service $

Unpaid claim

$

1

Transportation

$

2

Temporary lodging

$

3

Meals and

incidentals

$

4

Childcare

$

5

Care of a person with a

physical or mental

incapacity $

6

Disability - related

expenses

$

7

Remuneration of candidate's

representatives

$

8

Other

$

Totals carried forward from previous page $

Total $

Grand total (columns 1 to 8) $

Expenses paid by the candidate and not reimbursed $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Other Expenses and Outflows, from Part 3a, Column 3 PART 3d

No. Date yyyy/mm/dd

ED code Supplier Description Cheque no.

Amount paid

$

Contributed or

transferred property or

service $

Unpaid claim

$

1

Advances

$

2

Transfers

$

3

Principal payments on

loan $

4

Other

$

Totals carried forward from previous page $

Total $

Grand total (columns 1 to 4) $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Unpaid Claims and Loans, from Parts 3a and 2b PART 3e

No. Date yyyy/mm/dd

Supplier or lender

Unpaid claim

$

Unpaid claim

subject of legal proceedings

$

Unpaid loan

$

Unpaid loan subject

of legal proceedings

$

Totals carried forward from previous page $

Total $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

PART 3fCANDIDATE'S ELECTORAL CAMPAIGN RETURN Statement of Non-Monetary Transfers Sent to Affiliated Political Entities

No. Date sent yyyy/mm/dd

ED code Name of political entity receiving transfer Description

Nomination contestant

Non-monetary $

Registered association

Non-monetary $

Registered party Non-monetary

$

Totals carried forward from previous page $

Total $

Page ofED code Candidate's

surnameCandidate's given name

EC 20120

CANDIDATE'S ELECTORAL CAMPAIGN RETURN Campaign Financial Summary

PART 4

SECTION A – DATE OF RETURN

All campaign transactions up to the following date have been reported in this return (yyyy/mm/dd)

SECTION B – CONTRIBUTIONS, LOANS, TRANSFERS AND OTHER CASH INFLOWS

[1a] Monetary contributions – Part 2f

[1b] Non-monetary contributions – Part 2f

[1c] Loans - Not including overdraft(s) – Part 2f

[1d] Monetary contributions returned – Part 2c

[1e] Non-monetary contributions returned – Part 2c

[1f] Monetary transfers received – Part 2f

[1g] Non-monetary transfers received – Part 2f

[1h] Other cash inflows – Part 2f

[1i] TOTAL CAMPAIGN CASH INFLOWS (1a + 1c + 1d + 1f + 1h)

SECTION C – EXPENSES AND CASH OUTFLOWS

[ 2] Election expenses limit

[ 3] TOTAL ELECTION EXPENSES SUBJECT TO THE LIMIT - Part 3a

[4a] PLUS: Candidate's personal expenses – Part 3a

[4b] PLUS: Other expenses and outflows – Part 3a

[4c] TOTAL ELECTORAL CAMPAIGN EXPENSES (3 + 4a + 4b)

[5a] LESS: Contributed or transferred property or service – Part 3a

[5b] LESS: Unpaid claims – Part 3a

[5c] TOTAL CAMPAIGN CASH OUTFLOWS (4c - 5a - 5b)

SECTION D – MONETARY SURPLUS AND BANK RECONCILIATION

[6a] Total campaign cash inflows - Box 1i

[6b] LESS: Total campaign cash outflows - Box 5c

[6c] CAMPAIGN'S MONETARY SURPLUS (6a - 6b)

The amount in Box 6c should be equal to the amount in Box 7f

[7a] Total credits to bank account

[7b] LESS: Total debits to bank account

[7c] BANK ACCOUNT BALANCE AS OF THE DATE IN SECTION A (7a - 7b)

[7d] LESS: Total amount of outstanding cheques (attach a list)

[7e] PLUS: Total amount of deposits in transit (attach a list)

[7f] EFFECTIVE BANK ACCOUNT BALANCE (7c - 7d + 7e)

CAMPAIGN BANK ACCOUNT

ED code Candidate's surname

Candidate's given name

EC 20120