7:30 AM 1 John Lawwrence 2 Jodi Maroney 3 Att. 1 Motion John Lawrence 4 Motion John Lawrence 5 Motion John Lawrence 5.1 Att. 2 5.2 Att. 3 5.3 Att.4 5.4 Att.5 6 Att.6 7 8 Jodi Maroney 9 9:00 AM 10 John Lawrence Don 'Sparky' Leonard Jodi Maroney Denise Dodman Steve Walker Rachel Schwarz Aileen Murray Dave Shambrook Sandi Kearney Marilyn Lyons Alysson Storey Mary Logue Regrets: Adjournment CHATHAM-KENT HOSPICE FOUNDATION BOARD MEETING Wednesday, November 1, 2017 - 7.30 a.m. - 9 a.m. Chatham-Kent Hospice Community Room Time Att # Purpose/ Outcome Person Responsible Governance Committee Minutes - September 5, 2017 Item Topic Approval of the Agenda Welcome Hospice Heart Story Approval Minutes, September 27, 2017 meeting Conflict of Interest Declarations Consent Agenda Finance Committee Report & Financial Statements Board Education - Understanding Financial Statements Meeting Recorder Fall Promotion Benefit Gala Debrief Next Meeting-Wednesday, November 29, 2017 @ 5 p.m. followed by a Planned Giving Workshop Jennifer Wilson CKHF Charitable Return 2016-17 ▪ Donor Visits Distribution Guests Nathan McKinlay 1 of 1
Transcript
7:30 AM 1 John Lawwrence
2 Jodi Maroney
3 Att. 1 Motion John Lawrence
4 Motion John Lawrence
5 Motion John Lawrence
5.1 Att. 2
5.2 Att. 3
5.3 Att.4
5.4 Att.5
6 Att.6
7
8 Jodi Maroney
9
9:00 AM 10
John Lawrence Don 'Sparky' Leonard Jodi Maroney Denise Dodman
Next Meeting-Wednesday, November 29, 2017 @ 5 p.m.
followed by a Planned Giving Workshop
Jennifer Wilson
CKHF Charitable Return 2016-17
▪ Donor Visits
Distribution
Guests
Nathan McKinlay
1 of 1
1 CHATHAM KENT HOSPICE FOUNDATION BOARD MEETING – September 27, 2017
CHATHAM-KENT HOSPICE FOUNDATION
BOARD OF DIRECTORS MEETING MINUTES MEETING TITLE Chatham-Kent Hospice Foundation Board Meeting
DATE September 27, 2017
MEETING CALLED BY Chair
CHAIR/FACILITATOR John Lawrence
RECORDER Michelle Segeren
ATTENDEES Alysson Storey, Don ‘Sparky’ Leonard, Marilyn Lyons, Rachel Schwarz, Sandi Kearney, Denise Dodman, Aileen Murray, Steve Walker, Jennifer Wilson
TELECONFERENCE
ADMINISTRATION Jodi Maroney
Guests
Regrets Nathan McKinlay, Dave Shambrook
TOPICS DISCUSSION CONCLUSION: MOTION/ACTION
/FOLLOW UP
ACTION ITEMS: WHO/WHAT
1. Welcome John Lawrence welcomed everyone and the meeting was called to order. Alysson Storey (Community & Donor Relations Coordinator – interim) and Michelle Segeren (Donor Relations Assistant work-sharing with Mary Logue) were introduced.
2. Hospice Heart Story
Jodi Maroney shared a touching letter from James MacNeil at Life Transitions. He complimented the excellent care, guidance and compassionate professionalism that the C-K Hospice Administration, Foundation, Nursing staff and Volunteers offer to families, and shared his feelings as a fellow care giver when loved ones transition to his services.
2 CHATHAM KENT HOSPICE FOUNDATION BOARD MEETING – September 27, 2017
TOPICS DISCUSSION CONCLUSION: MOTION/ACTION
/FOLLOW UP
ACTION ITEMS: WHO/WHAT
3. Agenda Approval Added agenda item 10.5 ESC LHIN Info Update. Motion moved by Aileen Murray, seconded by Marilyn Lyons to adopt the agenda as amended. Carried
Motion
4. Conflict of Interest Declaration
None noted
5. Consent Agenda Approval
Motion moved by Sparky Leonard, seconded by Marilyn Lyons to accept the consent agenda which included the following items: Approval Minutes, August 23, 2017 Meeting; Executive Director’s Report September 2017; Governance Committee Minutes September 5, 2017; CKHF Governance Committee – Updated Workplan; Finance Committee Report & Financial Statements August 31, 2017. Carried
Motion
6. Governance Education Plan
Aileen Murray stated the Education Plan provides more structure around education. Each month, one or two policies will be reviewed. A Planned Giving workshop is scheduled for November, 2017, and a Donor Experience Survey will be completed in January with a workshop planned for March, 2018. The Committee is looking for one more member. It was suggested to consider past C-K Community Health Centre Volunteers.
Action
Jodi and Aileen to share documents with Nancy Kay;
7. Governance Minute – Board Portal Orientation
Jodi Maroney reviewed how to access the Foundation Board Portal: Click on Board Login (in small font at the very bottom of the
home page) > enter Username and Password > click on C-K Hospice Foundation button > Foundation Board button > Meetings (packages) > click on date of the meeting. If you hover over each Att #, it will bring you to that specific attachment. Scroll back to the top to view the agenda.
Members thought it would be beneficial to be given access to the other committees’ meeting packages.
Action
Jodi (1) to report on the timeliness of using the “forget password” option, and (2) will speak with Christine Elliott about posting the calendar of meetings;
3 CHATHAM KENT HOSPICE FOUNDATION BOARD MEETING – September 27, 2017
TOPICS DISCUSSION CONCLUSION: MOTION/ACTION
/FOLLOW UP
ACTION ITEMS: WHO/WHAT
It was agreed that only hard copies of the agenda and dashboard will be provided at future meetings, with the display of additional documents on the screen. Everyone was pleased with the one-click meeting package format.
Action Mary/Michelle to provide hard copies of the agenda and dashboard only at future meetings
8. Fund Development Dashboard
Jodi Maroney reviewed the Fund Development Dashboard for the period ending August 31, 2017. Highlights include:
Fundraising:
Only appears to have fallen below budget due to a
municipal pledge of $135,000 that was treated as a
Foundation revenue but was actually a grant to the
Hospice
Annual promotion is $55,000 below budget
It was noted that having Foundation staff in the Hospice building is
advantageous to charitable giving.
Donation Analysis: 335 new donors and 844 new donations with >85%
linked to memorial donations Hospice Facts:
211 residents came to Hospice last year with 302 in total (as of September 11, 2017)
Donor & Community Touchpoints: Meetings with the Knights of Columbus and Ursuline
Sisters were well received Upcoming events were reviewed:
Shoppers Drug Mart Chatham-Kent – Growing Women’s Health Campaign – September 9 – October 6, 2017 with seven stores participating
Action
Jodi to meet with Denise on (1) quarterly reporting of the number of memorial donations received with respect to residents versus non-residents, and (2) number of families served with the range on residents’ stay; Directors to extend appreciation for support to cashiers when visiting local Shoppers;
4 CHATHAM KENT HOSPICE FOUNDATION BOARD MEETING – September 27, 2017
TOPICS DISCUSSION CONCLUSION: MOTION/ACTION
/FOLLOW UP
ACTION ITEMS: WHO/WHAT
Designer Handbags for Hospice – Thursday, October 12, 2017 – Portuguese Club, Chatham. This will be in a bingo format. Jodi will be attending.
Other events include: Pretty in Pink Annual Fall Dinner Dance, Postma Fitness, Blenheim-Charity Escape Room, Hospice Benefit Gala and IODE Christmas House Tour.
Action Action
Directors to email Jodi if they will be attending any of the upcoming events (Dashboard, Att. 8)
9. Benefit Gala 2017 Jodi Maroney, Alysson Storey, Steve Walker and Rachel Schwarz
provided an update on progress to date on the Benefit Gala.
As of September 26, 184 tickets have been sold with a
target total of 250 tickets
Decorations will be ordered within the next few weeks
Radio ads will begin next week
Work continues with regard to auction experiences and
ticket promotion
Action Action Action
Jodi and Alysson will review the guest list of previous attendees to begin a phone campaign; Jodi, Alysson, Steve and Rachel to meet to discuss Gala details; Directors to continue to promote the Gala
10. Fall Promotion The timeline for the fall promotion is eight weeks (October 23 –
December 15, 2017) with a revenue goal of $200,000.
Promotional tactics include: newspaper, online and radio ads,
direct mail, employee payroll deduction program, Facebook posts &
ads, November newsletter and meeting with major donors.
Jodi Maroney attended the Regional Hospice Fund Development
Day in Guelph on September 22, 2017 and found our hospice
consistent with others. The next meeting is scheduled for February,
2018. Jodi is interested in fine tuning Sumac best practices and
Action Action Action
Jodi to review visitation lists and strategize on direct-asks; Jodi and Aileen to discuss digital advertising
Directors to watch their
email for CAGP
Appreciation evening on
5 CHATHAM KENT HOSPICE FOUNDATION BOARD MEETING – September 27, 2017
TOPICS DISCUSSION CONCLUSION: MOTION/ACTION
/FOLLOW UP
ACTION ITEMS: WHO/WHAT
exploring more complex fundraising.
The CAPG Webcast training session on September 26, 2017
highlighted practical takeaways and revealed that the average
donor across Canada is senior 75 years+.
November 16, 2017 at
the Active Lifestyle
Centre (5:00 p.m.
drop-in)
10.5 ESC LHIN Info Update
Ralph Ganter (ESC LHIN) spoke with Jennifer Wilson on capital
dollars for hospice care for new projects ($200,000/bed). The ESC
LHIN currently has 40 beds but would like to increase this to 58-60
beds..
11. Next Meeting The next meeting is scheduled to be held on Wednesday,
November 1, 2017 @ 7:30 a.m.
12. Adjournment Motion moved by Aileen Murray and seconded by Jennifer Wilson to adjourn the meeting at 8:57 a.m. Carried
Motion
_______________________ _________________________ John Lawrence, Chair Date
1 CHATHAM-KENT HOSPICE FOUNDATION – GOVERNANCE COMMITTEE MEETING MINUTES – August 8, 2017
CHATHAM KENT HOSPICE FOUNDATON
Governance Committee
TOPICS DISCUSSION Conclusion: motion/action/ follow up
Action items: who/what
1. Welcome Aileen welcomed everyone to the meeting this morning.
Aileen Murray
2. Reflection Jodi Maroney read a letter of thanks from a teenage grandson of a past resident: He was thanking the hospice for the special touches, the special moments and celebrations prepared just for his grandmother as well as the wonderful care she received. He included a personal monetary donation to the hospice.
Jodi Maroney
3. Approval of the Agenda
Note: The Policy Review shall begin in October 2017
Add the Policy Review Schedule as Agenda Item #11
Motion: Moved by Jennifer Wilson, seconded by Jo-Ann Patterson to approve the agenda as circulated. Carried.
Motion Aileen Murray
MEETING TITLE Governance Committee
DATE September 5, 2017
MEETING CALLED BY Committee Chair
CHAIR/FACILITATOR Aileen Murray
RECORDERS Elaine McCorkle
ATTENDEES Aileen Murray, Allan Klinck, Jodi Maroney, Jo-Ann Patterson, Jennifer Wilson
ADMINISTRATION Jodi Maroney
REGRETS John Lawrence, Barb McEwan
2 CHATHAM-KENT HOSPICE FOUNDATION – GOVERNANCE COMMITTEE MEETING MINUTES – August 8, 2017
TOPICS DISCUSSION Conclusion: motion/action/ follow up
Action items: who/what
4. Conflict of Interest Declarations
None noted Aileen Murray
5. Approval Minutes, August 8, 2017
Suggested changes to the Portal – Jodi Maroney will change the portal access process for the board meetings to one package holding all the documents thereby eliminating extra mouse clicks. Motion: Moved by Jo-Ann Patterson, seconded by Jennifer Wilson to approve the minutes of August 8, 2017 as circulated. Carried.
Motion Jodi Maroney to make changes
6. Work Plan Work Plan “Updated” date should be as of September 5th, 2017 not June 26, 2017.
Item #8 Policy Review Schedule is moved to September 2017
Item #2 Board Orientation – outstanding documents: Title change from Role to Duties of Executive Director & Staff
Motion: Moved by Jennifer Wilson, seconded by Jo-Ann Patterson to accept the amended Work Plan document and recommend it to the Chatham Kent Hospice/Foundation Board. Carried.
Item #3 Board Education Plan & Training Schedule to be scheduled again in November 2017.
Add Governance Education Plan Review & Update to the November 2017 schedule
Add Planned Giving Workshop to November 2017 schedule.
Add Board Education Budget & Expectation Policy to the December 2017 schedule.
Add Donor Survey to December/January/February 2018 schedule.
Add Donor Surveying Workshop to the March 2018 schedule.
Motion
Jodi Maroney to revise and share in next Board package
3 CHATHAM-KENT HOSPICE FOUNDATION – GOVERNANCE COMMITTEE MEETING MINUTES – August 8, 2017
TOPICS DISCUSSION Conclusion: motion/action/ follow up
Action items: who/what
Motion: Moved by Jennifer Wilson, seconded by Jo-Ann Patterson to accept the amended Work Plan and recommend it to the Chatham Kent Hospice/Foundation Board. Carried.
7. Board Education Plan
Jodi will share a short education topic at each Board meeting and include resources on portal. Suggestion: Perhaps Committee Members could be invited to the Education Workshops. Addition to Board Meetings - Governance Minute = 1 orientation document & policy review: September – Board Portal Orientation October – Bylaws November – Affirmation/Conflict of Interest/Confidentiality/Code of Conduct The Board Education Plan will be reviewed again at the November 2017 meeting. Motion: Moved by Jennifer Wilson, seconded by Allan Klinck to accept the Board Education Plan document and recommend it to the Joint Chatham Kent Hospice/Foundation Board. Carried.
Motion Aileen Murray to share Education Plan with Board
8. Board Orientation Documents
Jodi Maroney will contact finance regarding the preparation of a “financial” package for a “teach/review” of financials, including how to read and understand the organizational financial statement. All highlighted items are currently being worked on.
Follow up Jodi Maroney
Jodi Maroney
4 CHATHAM-KENT HOSPICE FOUNDATION – GOVERNANCE COMMITTEE MEETING MINUTES – August 8, 2017
TOPICS DISCUSSION Conclusion: motion/action/ follow up
Action items: who/what
9. Job Descriptions Job Descriptions (Board Chair, Vice Chair, Director, Committee Chair, Committee Member) – Jo-Ann, Allan, Barb to complete by October 2017.
Volunteer Job Description to be completed by Jodi Maroney by November 2017.
Follow up Jo-Ann Patterson Allan Klinck Barb McEwan Jodi Maroney
Jo-Ann Patterson
10. Committee Vice Chair and Member Recruitment
Allan Klinck has accepted the position of Chatham-Kent Hospice Foundation Governance Committee Vice Chair
11. Policy Review Schedule
Policy Review Schedule Dates for October 2017: Restricted and Designated Gifts Receipt Issuance for Donations Donor Recognition Date of Issue should read October 26, 2016
Follow up Aileen Murray Jodi Maroney
Aileen Murray
12. Meeting Schedule Meeting Schedule for 2017: October 2, 2017 November 6, 2017 December 4, 2017 8:00 -9:30 A.M.
Aileen Murray
13. Meeting Adjourned
Motion: Moved by Allan Klinck, seconded by Jo-Ann Patterson to adjourn the meeting.
Chatham-Kent Hospice FoundationBalance Sheet As at 0913012017
ASSET d
Current Assets
Scot¡a Account # 02885 19
ctBc rGA461 13
TOTAL BANK
Accounts Receivable
Total Receivable
Total Current Assets
938,094.85
13,835.76
TOTAL ASSET
LIABILITY
Current Liabilities
Accounts Payable
Accured Liabilities
Hosp¡ce Payable
Wages Payable
Deferred Distr¡buton Hospice
HST Paid on Purchases
GST/HST Owing (Refund)
Total Current Liabi¡¡ties
-5,959.71
TOTAL LIABILITY
EQUITY
Reta¡ned Earnings
Retained Earnings - Previous Year
Current Earnings
Total Retained Earnings
TOTAL EQUITY
LIABILITIES ANO EQUITY
231,373.38
938,094.85
13,835.76
1,183,303.99
1,183,303.99
2,899.30
2,000.00
235,121.99
3,187.84
200,000.00
-5,959.71
437,249.42
437,249.42
686,900.26
59,154.31
746,054.57
746,054.57
1,183,303.99
l*I Canada Revenue Agence du revenuAgency du Canada
OTTAWAON K1AOLs
REGISTERED CHARITYBASIC INFORMATION
0213 3 B
Place this label on the envelope/package
Êou are sending.
CHARITIES DIRECTORATECANADA REVENUE AGENCYOTTAWA ON K1AOL5trtfitrFdT,s coPY
Chatham-Kent HospiceFoundation34 WEIJTJTNGTON ST ECHATHAM ON N7M 3N7
23 2017-03-31 80900 1597 RR 0001 3056047
New ma¡ling address
The back of this form contains important information about your charity.
23 2017-03-31 80900 1597 RR 0001 3056047I
23 20't7-03-31 80900 1597 RR 0001 3056047
23 2017-03-31 80900 1597RR0001 3056047
1F725XETF725
23 2017-03""s1 80900 1597 RR 0001 3056047
you must rdtsff.this sheet with your information return as it is an integral part of your return.
Wfren you iignrysur Begistered Charity Information Return, you are also confirming the
informâlion .m*tis sheet'
o This basic ifkrmation sheet contains information that we have on file for the charity.
o For your.caffinience, you may make changes to the information on this form where a box is provided.
o To make cffi€es to any other information, you must send us a written request with appropriale documentation
tililil|ilililil
Designation:
Public Found¿itiwr
Telephone numbÞr:
(519) 354.31,¡,S
Fax number:
ril illilffi il llll lill lffi lil lffi lil lil ilil |il |il
Email address:
I N FO@CHATHTAI$KENTH OS P I C E. COM
Web site address:
Public contact naFnÐoF Position :
JODI MAROÍ{,EW
Names the charity;islüown by other that its registered name:
Program areas:tné three primryareas in which the charity is now carrying onprograms to ad¡ñew its charitable purposes are listed below'The program arèG are ranked according to the percentage oftime and resour.cæsdevoted to each program area. (See theguide for a desc{ilion of programs and field codes.)
RankF¡eldcode
.kolemphas¡s
1
2
3
BN/registration number:
80900 1597 RR 0001
Telephone number
Fax number
Email address
Web site address
Public contact name or position:
Names the charity is known by other that its registered name:
Program areas:
lf the charity's primary areas of activity for the fiscal periodending 2017-03-31 were different from those for theprevious fiscal period, correct the information in the boxbelow. (See the guide for a description of programs andfield codes.)
Rank DBscriptionFisldcode
'/o olêmphâsis
1
2
3
Fiscal period end
03-31
Registration date
2015-07-31
Description
)K Hospice Fdn 2O17.T17>-017-09-26 O7:15
I*t 1å:ñ:; """"n'" Asenace du revenu
Registered Gharity lnformation Return
23 2017-03-31 80900 1597 RR 0001 3056047
Chatham-Kent Hospice Foundation809001 597
Protected B when completed
2017-03-31
Section A: ldentification. To help you fill out this form, refer to Guide T 4Q33, Completing the Registered Charity lnformation Return. ll can be found at cra.gc.ca/E/pub/tg/t4033.
Note: Even if a charity is inactive, an informatiôn return must be filed to maintain its registered status
lf you did not receive a barcode label to attach to the return, complete the following:1. Charity name:
Chatham-Kent2. Return for fiscal 3. BN/registration number: 4. Web address applicable)
809001597RR001
¡@tr Yes x No[ll Was the charity in a subordinate position to a parent organization?
lf yes, give the name and BN/registration number of the organization.
Year Month Day
Name: BN (if applicable)
EEI r-r". the charity wound-up, dissolved, or terminated operations?
[fl t, yom charity designated as a public foundation or private foundation?
¡@¡@
Yes
Yes
No
No
lf yes, you must complete Schedule 1, Foundations. Refer to Form TF725, Registered Charity Basic lnformation Sheef, to confirm the designation.(Form TF725 is part of the return.)
X
X
Section B: Directors/trustees and l¡ke officialsf!!l ell charities must complete Form T1235, Directors/Trustees and Like Officials Worksheet. Only the public information section of the worksheet is
- available to the public. Charities subject to the Onlailo Corporafibns Acf must also complete Form RC232-WS, Director/OfficerWorksheet and Ontario
Corporations lnformation Act Annual Return.
eneral informationSection C: Programs and gxEII w"r the charity active during the fiscal period? Yes No
lf no, explain why in the "Ongo¡ng programs" space below at C2.
lãã tn tne space below, describe all ongoing and new charitable programs the charity carried on this fiscal period to further its purpose(s) (as defined in its
- governing documents). "Programs" includes all of the charitable activities that the charity carries out on its own through employees.or volunteers as well
ãs through qualified donees and intermediaries. The charity may also use this space to describe the contríbutions of its volunteers in carrying out its
activities, for example, number of volunteers and/or hours. Do not include the names of employees or volunteers. Grant-making charities should
describe the types of organizations they support. Do not describe fundraising activities in this space.
Do not attach additional sheets of or annual reports,Ongoing programs:
To donate funds to Chatham-Kent Hospice Inc. or any registered charity which
facilitates the provision of end of life care or palliative services in
Municipality of Chatham-Kent, Ontario.
New programs:
Approval code: 13001
CanadäPage
T3010 E (17)
CK Hospice Fdn2017.1172017-09-26 07:15
2017-03-31
Fiscalperiod end -20L7:93tL -
Chatham-Kent HosPice Foundation'809001597
Protected B when comPleted
1BN/registration number 809001597RRo0
E Political Activities
EE o¡o the charity make gifts or transfer funds to qualified donees or other organizations?
tf yes, you must complete Form T1236, QuameA Oäeis Worksheet/Amounts Provided to Other Organizations
q 3;î,'å".,:îiiirï",",*,',îlî;ülå[:ïïî,:,îïffiìåï:H,l[:::1,î$]31?ilì¿l 'lî]îî'åÉ',iiiJ3iiå:Til"''activity/program/project outside Canada?lf yes, you must complete Schedule 2, Activities Outside Canada'
Yes
YesE@
No
No
Canadian charities, as well as certain otherregistereddonees are otherto qualified donees. Qualifiedcharities maY makebed i
X
x
ities only if the activities are to its charitable purposes, and lim ited in extent.A reg istered charity may pursue political activ
public decision of any level of governinent nside ority that explicitly communicates to the
$
(d) Total amount received from outside Canada that was directed to be spent on political activities'
lf you entered an amount on line 5032 you must complete Schedule 7, Potiticat Actívities, Table 3'
@ $
ffi lf the charity carr¡ed on fundraising activities or engaged third parties to carry on fundraising activities on its behalf, tick all fundraising methods that it
E used during the fiscal Period:
@ e +$":ifü,i:''itrinvradio/ @T
(a) Did the charity carry on any political activities during the fiscal period, including making gifts to qualified
donees that werê intended for political activities?
lf yes, you must Çomplete Schedule 7, Political Activities.
(b) Total amount spent by the charity on these political activities.
(c) of tne amount at line 5030, the total amount of gifts made to qualified donees
XBN/registrationnumber 809001597RR001 Fiscal period end 2017-03-3I
pfll OU the charity receive any gifts in kind (non-cash gifts) for which it issued tax receipts?lf yes, you must complete Schedule 5, Gifts in kind.
!@ oiO the charity acquire a non-qualifying security?
EIE O¡O the charity allow any of its donors to use any of its property? (except for permissible uses)
El[ OiO the charity issue any of its tax receipts for donations on behalf of another organization?
EEI oio the charity ha¡e direct partnership holdings at any time during the f¡scal period?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
X
X
X
X
Section D: Financial information
Fill out either Section D or Schedule 6, Detailed financial information.
Skip this section if any of the following applies to the charity:
(a) The charity's revenue exceeds S100,000.(b) The amount of all property (for example, investments, rental properties) not used in charitable activities is more than $25,000.(c) The charity has permission to accumulate funds during this fiscal period.
Show all amounts to the nearest Canadian dollar. Do not enter "See attached financial statements." All relevant fields must be filled out.
@T Accrual CashEÛ Wæ the financial information reported below prepared on an accrual or cash basis?
@ Srrr"ry of financial position:
Using the char¡ty's own financial statements, enter the following:
Did the charity own land and/or buildings? .
Total assets (including land and buildings)
Total liabilities
Did the charity bonow from, loan to, or invest assets with any non-arm's length persons?
$t R"u"nue'
Did the charity issue tax receipts for gifts?
lf yes, enter the total eligible amount of all gifts for which the charity issued tax receipts
Total amount of 10 year gifts received !!@Total amount received from other registered charities
Total other gifts received for which a tax receipt was not issued by the charity(excluding amounts at lines 4575 and 4630)
Did the charity receive any revenue from any level of government in Canada?
lf yes, total amount received
Total tax-receipted revenue from all sources outside of Canada rrrFrr(government and non-government) WnTotal non tax-receipted revenue from all sources outside of Canada (government and non-government)
Total non tax-receipted revenue from fundraising .
Total revenue from sale of goods and services (except to any level of government in Canada)
Other revenue not already included in the amounts above
Total revenue (add lines 4500,4510 to 4570, and 4575 to 4650)
þ!l Expenditures:
Professional and consulting fees
Travel and vehicle expenses
All other expenditures not already included in the amounts above (excluding gifts to qualified donees)
Total expenditures (excluding gifts to qualified donees) (add lines 4860, 4810, and 4920)
Of the amount at line 4950:
(a) Total expenditures on charitable activities . EEE0(b) Total expenditures on management and administration [[@
Total amount of gifts made to all qualified donees
Total expenditures (add lines 4950 and 5050)
$
Yes
Yes
E@@@@@E@
@@E@@@@EU@@
No
[ves I
No
No
$
E@
@E@@
$
$
Yes No
$
$
$
$
$
$
$
$
$
$
$
Approval code: 13001
Page :
$
$
$
$
íniå'd-rîåli 2017r17 2017-03-31
Fiscal period end 2077-03-3L
Chatham-Kent Hospice Foundation809001 597
Protected B when completed
BN/registration number 809001597RR001
This return must be signed by a Person who has authority to sign on behalf of the charity. lt is a serious offence under the lncome Tax Actlo provide false
or decePtive ínformat¡on'
I certifY that the information given on this form, the basic information sheet, and any ettachment is, to the best of my knowledge, correct, complete,
and current'
ø Enter the PhYsical address
are not sufficient'
of the charity and the address in Canada for the charity's books and records. Post office box numbers and rural routes
Signature:Name
Date: Telephone number:Position in charitY:
DI
Section F :confidential data
Address for the 's books and recordsPhysical address ofthe
street address
and postal codeProvince or
ø Name and address of individual who completed this return
Name:
nCompanY name (if applicable):
address
LineComplete street
mCity, province or tenitory' and postal code:
ls this the same individual who certified in Section E? xYes No1
Telephone number:
Priva statementpersonal information is collected under the authority of lhe lncome Tax Act and is used to establish and validate the identity and contact information of
directors, trustees, officers and/or like officials and authorized representatives of the organization. This information will also be used as a basis for the
indirect collection of additional personal information from olher internal and efernal sources, which includes social insurance number (SlN), personal tax
information, and relevant financial and biographical information, which may be used to assess the overall risk of registration with respect to the obligations
of registration as outlined in the Act and the common law. The social insurance number is collected pursuant to subsection 237 of the Act and is used foridentification purposes.
The Canada Revenue Agency (CRA) will make this form and all attachments ava¡lable to the public on the Charities Directorate website, except forinformation or data identified as confidential. Personal information may also be disclosed to the organization in question and/or its authorized representativesand other third parties pursuant to the disclosure provisions under Section 241 of the Act. Personal information may also be shared w¡th other governmentdepartments and agencies under information-sharing agreements in accordance with the disclosure provisions under Section 241 of the Act. Incomplete orinaccurate information may result in a range of actions including suspension of tax-receipting privileges, up to and including revocation of registered status.
lnformation is described in Charities Program CRA PPU 200 and is protected under the Privacy Act.lndividuals have a right of protection, access to andcorrection or notation of their personal information. Please be advised that you are entitled to complain to the Privacy Commissioner of Canada regarding ourhandling of your information.
Notlflcation to directors and like officials: The CRA strongly encourages the charity to voluntarily inform directors and like officials that their personallnformation has been collected and disclosed to the CRA for the submission of its annual information return.
X I confirm that I have read the pr¡vacy statement above.
ChecklistA charity's complete annual information return includes:r Form T3010, Registered Charity tnformation Return, and ail apptìcable schedules;¡ Form TF725, Registered Charity Basic Information gheet;. a copy of the charity,s financial statements;r Form T1235, Directors/Trustees and Like Officiats Worksheeti
' l?Tl9,-23?-ttt!|, oire.clortofficer Worksheet and Ontario Corporations tnformatÌon Act Annual Return,or Form Rc232, Ontario Corporations,nrcrmafion Act Annuat Return (if applicable);¡ Form T1236, Quatified Donees Worksheet/Amounts Provided to other organizafrbns (if applicable); and
' Form T2081 , Excess corporate Holdings worksheet for private Foundations(if applicable).
lf flnanclal statements are not incruded, your charity's registration may be revoked.
Approval code: 13001
Page 4
E,
vNnuüptuËrunzvILII¡ ZU I /-UJ-J I
2017-O9-26 O7:15
BN/registrationnumber 809001597RR001 Fiscal period end 2017-03-31
L,natnam-nenI nosptce r0unaalton809001 597
Protected B when completed
Schedule 1FoundationsYes
Yes
Yes
Yes
¡@Etr
@¡q
EA
Did the foundation acquire control of a corporation?
Did the foundation incur any debts other than for current operating expenses, purchasing or selling investments,or in administering charitable activities?
For pr¡vate foundations only:
ll Did the foundation hold any shares, rights to acquire shares, or debts owing to it that meet the definition of aE non-qualified investment?
E OiO the foundation own more than 2ok of any class of shares of a corporation at any time during the fiscal period?
If yes, you must complete and attach Form T2081, Excess Corporate Holdings Worksheet.
No
No
No
No
x
X
Schedule 2Activities outs¡de Canada
For more information about carrying on activities outside of Canada, go to cra.gc.ca/chrts-gvng/chrts/plcy/cgd/tsd-cnd-eng.html'
I fotrt expenditures on activities/programs/projects carried on outside Canada, excluding gifts to qualified donees ![Ell Were any of the charity's financial resources spent on programs outside of Canada under any kind of an
- arrangement including a contract, agency agreement, or joint venture to any other individual or organizat¡on ¡¡¡¡¡(excluding gifts to qualified donees)? ' Wlf yes, enter the amounts of the tolal reported on line 200 transferred to these individuals/organizations as required in the following table:
$
[ves E*o
Name of individual/organizationUsing the country codes at the endof Schedule 2, enter the code where
the activities were carried out.
Amount ($)Show amounts to the nearest
Canadian dollar
!l Uring the list below, enter the country code where the charity itself carried on programs or devoted any of its resources.
!l nr" any projects undertaken outside Canada funded by the Canadian lnternational Development Agency (CIDA)?
lf yes, what was the total amount the charity spent under this arrangement?
[l W"r" "ny
of the charity's activities outside of Canada carried out by employees of the charity?
I Wer" any of the charity's activities outside of Canada carried out by volunteers of the charity?
I t. tn" charity exporting goods as part of its charitable activities?
lf yes, list the items being exported, their value (in Canadian dollars), their destination and the country code.
@@@@@
Yes No
$
Yes
Yes
Yes
No
No
No
Item Value Destination (city/region) Countrycode
Approval code: 13001
Page I
)K Hospice Fdn 2017.T17O17-09-26 07:15
BN/reg¡stration number 809001597RR00 1 Fiscal period end
2017-03-3'l
Gountry codes
Chatham-Kent HosPice Foundation809001597
31
AF-Afghanistan
AL-Albania
DZ-Algeria
AO-Angola
AR-Argentina
AM-Armenia
AZ-Azerbaijan
BD-Bangladesh
BY-Belarus
BT-Bhutan
BO-Bolivia
BA-Bosnia and Herzegovina
BW-Botswana
BR-Brazil
BN-Brunei Darussalam
BG-Bulgaria
Bl-Burundi
KH-Cambodia
CM-Cameroon
CF-Central Af rican Republic
TD-Chad
CL-Chile
CN-China
CO-Columbia
KM-Comoros
CD-Democratic Republic of Congo
CG-Republic of Congo
CR-Costa Rica
Cl-CÖte d'lvoire
HR-Croatia
CU-Cuba
CY-Cyprus
DK-Denmark
DO-Dominican RepublicEC-Ecuador
EG-Egypt
SV-El Salvador
ET-Ethiopia
FR-France
GA-Gabon
GM-Gambia
GE-Georgia
DE-Germany
GH-Ghana
GT-Guatemala
GY-Guyana
HT-Haiti
HN-Honduras
lN-lndia
lD-lndónesia
lR-lran
lQ-lraq
lL-lsrael
PS-lsraeli Occupied Tenitories
lT-ltaly
JM-Jamaica
JP-Japan
JO-Jordan
KZ-Kazakhslan
KE-Kenya
KP-North Korea
KR-South Korea
KW-Kuwait
KG-KYrgYzstan
LA-Laos
LB-Lebanon
LR-Liberia
MK-Macedonia
MG-Madagascar
MY-MalaYsia
ML-Mali
MU-Maurltius
MX-Mexico
MN-Mongolia
ME-Montenegro
MZ-Mozambique
MM-Myanmar (Burma)
NA-Namibia
NL-Netherlands
Nl-Nicaragua
NE-Niger
NG-Nigeria
oM-Oman
PK-Pakistan
PA-Panama
PE-Peru
PH-Philippines
PL-Poland
QA-Qatar
RE-Réunion
RO-Romania
RU-Russia
RW-Rwanda
SA-Saudi Arabia
RS-Serbia
SL-Sierra Leone
SG-Singapore
SO-Somalia
ES-Spain
LK-Sri Lanka
SD-Sudan
SY-Syrian Arab Republic
TJ-Tajikistan
TZ-United Republic of Tanzania
TH-Thailahd
TL-Timor-Leste
TR-Turkey
UG-Uganda
UA-Ukraine
GB-United Kingdom
US-United States of America
UY-Uruguay
UZ-Uzbekistan
VE-Venezuela
VN-Vietnam
YE-Yemen
ZM-Zambia
ZW-Zimbabwe
Use the following codes for countr¡es not listed above:
QS-Other countries in Africa
QR-Other countries in Asia and Oceania
QM-Other countries in Central and South America
QP-Other countrles in Europe
QO-Other countrles in the Middle East
QN-Other countries in North America
Approval code: 13001
Page 6
ur\ rlosptce Fqn zu1 /. I 1/2017-09-26 O7:15
BN/registrationnumber 809001597RR001
2017-Q3-3
Fiscal period end 2017-03-31
Chatham-Kent Hospice Foundat¡on809001 597
Protected B when completed
Schedule 3Com
!l t"l Enter the number of permanent, full-time, compensated positions in the fiscal period. This number should
- represent the number of positions the charity had including both managerial positi'rns and others, and shouldnot include independent contractors. Do not enter a dollar amount
(b) For the ten (10) highest compensated, permanent, full-time positions enter the number of positions that arewithin each of the following annual compensation categories. Do not tick the boxes, use numbers.
$80,000 - $1 19,999
$200,000 - $249,999
$350,000 and over
$
$ 131.290
@@@
$1 - $39,999
$120,000 - $159,999
$250,000 - $299,999
$40,000 - $79,999
$160,000 - $1 99,999
$300,000 - $349,999
I tar ,i:'?tgÌ;J,il::''o:Tl'T: :'o:i-ï: I'i ":iTl'? :ï::*:)::::i:: i^::lî'l'"il:y o::'in
(b) total expenditure on compensation for part-time or part-year employees in the fiscal period.
El fotrt expenditure on all compensation in the fiscal period.
2
1
Schedule 4Confidential dataThe information in thÍs schedule is for the CRA's use and may be shared as permitted by law (for example, with certain other governmentdepartments and agencies).
1. lnformation about fundraisers
Enter the name(s) and arm's length status of each external fundraiser.
Name At arm's length? Yes/No
2. lnformation about donors not resident in Canada
Complete this schedule to report any gift of any kind valued at $10,000 or more received f'om any donor that was not resident in Canada and was notany of the following:. a Canadian citizen, nor
. employed in Canada, nor
. carrying on business in Canada, nor
. a person having disposed of taxable Canadian property.
Enter the name of each donor and the value of the gift in the chart below. Tick whether the donor was an organization (for example a business, corporateentity, charity, non-profit organization), a government or an individual.
Name Value Organization Government lndividual
Schedule 5Gifts in kind
ll fi.f. all types of gifts in kind received for which a tax receipt was issued
fl enter tne total amount of tax-receipted gifts in kind @ $
)K Hospice Fdn 2017 'f '17
2O17-09-26 07:15
2017-03-31
01 Fiscal Period end 2017-03-31
Chatham-Kent Hospice Foundation809001 597
Protected B when completed
BN/registration number 809001597 Schedule 6Detailed financial information
Fill out this schedule if any of the following applies to the charity:
(a) The(b) The
(c) The
charity's revenue exceeds $100,000.not used tn char¡table activities ts than $25 ,000.
propertY (for ple, investments rental properties) moreamount oÍ all exam
has permigs ion to accumu late funds during th t9 fiscal period.
Was the financial information reported below prepared on an accrual or cash basis? @ X Accrual Cash
dollar. fields ustm filledbe out.financialattached statements. Ail relevant"seeenternotDoGanadiannearestthetoamouall ntsShow
Statement of financial
Assets:Cash, bank accounts, and short-term
¡nvestmentsAmounts receivable from non-arm's
length persons
Amounts receivable from all others
lnvestments in non-arm's length persons
Long-term investments
lnventories
Land and buildings in Canada
Other caPital assets in Canada
Capital assets outside Canada
Accumulated amortization of capital assets
Other assets10 yeargifts....
Statement of oPerations
Revenue:
@ $
Totalassets(addlines4100to4170) "' IEEEre
Liabilities:
tr@ $ 1,0 50,512 Accounts payable and accrued liabilities
$Deferred revenueAmounts owing to non-arm'slength persons
Other liabilitiesTotal liabilities (addlines 4300 to 4330) . . . .
$ 12,690
$$
$Amount included in lines 4150,4155,4160,4165 and 4170 not used incharitable activities$
$
$
ffiffiE@
@
@
ffi
$ 346,068$ 30,234
$$
$ 826,040
$ 337,954 t
6,222
$
$ 4,074
$$
$
$ 40,040$
$$$
@
Total eligible amount of all gifts for which the charity issued tax receipts
Total eligible amount of tax-receipted tuition fees . . . . . ffi
Total amount of ',l0 year gifts received
Total amount received from other registered charities
rãìri .fl,,"iôin. received for which a tax receipt was not issued by the charity (excluding amounts at
lines 4575 and 4630)
Total revenue received from federal government'
Total revenue received from provincial/territorial governments
Total revenue received from municipal/regional governments
Totaltax.receiptedrevenuefromallsourcesoutsideofCanada(governmentandnon-government) .. @Total non tax-receipted revenue from all sources outside canada (government and non-government)
Total interest and investment income received or earned
Gross proceeds from disposition of assets !!@Netproceedsfromdispositionofassets(showanegativeamountWithbrackets)Gross income received from rental of land and/or buildings
Total non tax-receipted revenues received for memberships' dues and association fees
Total non tax-receipted revenue from fundraising
ïotal revenue from sale of goods and services (except to any level of government in canada)
Other reveniJe not already included in the amounts above
Specify type(s) of revenue included in the amount
reported at 4650 @
$
$
$$$$
$
Approval code: 13001page I
41104120413041404150415541 60
416541 664170
376,302
4600461 0
4620463046404650
1 2tTotal revenue (add lines 45OO,451}to 4560, 4575,4580, and 4600 to 4650) @
Total expenditure on all compensation (enter the amount reported at line 390 in Schedule 3, if applicable)
Fair market value of all donated goods used in charitable activities
Purchased supplies and assets :
Amortization of capitalized assets
Research grants and scholarships as part of charitable activities
All other expenditures not included in the amounts above (excluding gifts to qualified donees)
Specify type(s) of expenditures included in the amountreported al4920
Total expenditures before gifts to qualified donees (add lines 4800 to 4920)
Of the amounts at lines 4950 and 5031 (reported at C5 Political Activities (c))
(a) Total expenditures on charitable activities
(b) Total expenditures on management and administration
(c) Total expenditures on fundraising(d) Total expenditures on political activities, inside or outside Canada,
from question C5 (b)
(e) Total other expenditures included in line 4950
Total amount of gifts made to all qualified donees
Total expenditures (add lines 4950 and 5050)
$
$$
$
$
Other financial information
Permission to accumulate property:
Only registered charities that have written permission to accumulate should complete this section.r Enter the amount accumulated for the fiscal period, including income earned on accumulated funds
. Enter the amount disbursed for the fiscal period for the specified purpose
Permission to reduce disbursement quota:
lf the charity has received approval to make a reduction to its disbursement quota, enter the amount for the fiscal period
Property not used in charitable activities:
Enter the value of property not used for charitable activities or administration during:. Íhe 24 months before the beginning of the fiscal period
. The 24 months before the end of the fiscal period
1
9001
Insurance
$ 200,246
100,051100.195
ffi
EH
$
$
327 1
$
@ $
$
$
4800481 0
4820483048404850486048704880489048914900491 0
4920
Approval code: 13001
Page {
)K HosPice Fdn 2O17.T17,-O17-09-26 07i15
BN/registration number 809001597RR001
2017-03-31
Fiscalperiodend 20t7-03-3t
Chatham-Kent Hospice Foundation809001597
Protected B when completed
Schedule 7Political activities
only if the activities are non-partisan, related to its charitable purposes, and lim ited tn extent. A political
to the public that a law, policy or decision of any level of govefn ment inside or outside Canada should beor
g Describe the charity's political activities, including gifts to qualified donees intended for political activities, and explain how these relate to its
charitable Purposes' r
E ldentify ttre way the charity participated in or carried out political activities during the fiscal period.
Resources usedTick all the boxes that apply
Staff Volunteers Financial Property
trMedia releasgs and advertisements
TConferences, workshops, speeches, or lectures
Publications (printed or electronic)
Rallies, demonstrations, or public meetings
TPetitions, boycotts (calls to action)
Letter writing campaign (printed or electronic)
lnternet (website, social media (Twitter, YouTube)) l nGifts to qualified donees for political activities TOther (specify):
700
701
702
703
704
705
706
707
708
Funding from outside of Canada for political activities
I tf tne char¡ty entered an amount on line 5032, complete the fields below. Enter the political activity that the funds were intended to support, lhe amountreceived from each country outside Canada, and the corresponding country code (using the codes provided in Schedule 2), For more information on howto complete this table, see Guide T4033.
Political activity Amount Code
Approval code: 13001paqê 10
CK Hospice Fdn 2017 .T172017-09-2515:04
l*l canada Revenue âg"Jjf"åå'""""u þirectors/Trustees and Like Officials Worksheet
Directors/tñ¡stees and iike officials are persons who govern a registered charity. See the Help for information on filling out this form.
Total number of directorc/trustees and like officials: 10
Qualified donees worksheet / Amounts provided to other organ¡zat¡ons
Registered charities can make gifts to qualified donees. Enter the required information for gifts made to each qualifiçd donee or other organizationSee the Help for information on filling out this form.
Total number of qualified donees/other organizations: 1
Name of organization:
Chatham Kent Hosoice
Associated charity:
Yes NoxBN/Registration number:
84394 4430 RR0001
City and ProvÆen:
Chatham ON
Amount of gifts in kind $ Total amount of gifts $ 327,L83.94
Was any part of the gift intended for political activities? Yes No lf yes, enter amount $x
Name of organization Associated charity:
Yes No
BN/Registration number: City and Prov/Ten:
Amount of gifts in kind $ Total amount of gifts $
Was any part of the gift intended for political activities? Yes I *o lf yes, enter amount $
Name of organization: Associated charity:
Yes No
BN/Registration number: City and Prov/Terr:
Amount of gifts in kind $ Total amount of gifts $
Was any part of the g¡ft intended for political activities? Yes E to lf yes, enter amount $
Name of organization: Associated charity:
Yes No
BN/Registration number: City and Prov/Terr:
Amount of gifts in kind $ Total amount of gifts $
Was any part of the gift intended for political activities? Yes E to lf yes, enter amount $
Name of organization: Associated charity:
Yes No
BN/Registration number: City and Provfferr:
Amount of gifts in kind $ Total amount of gifts $
Was any part of the gift intended for political activities? Yes I *o lf yes, enter amount $
Approval code: 1300f
CanadäT1236 E (15)
Page 1
l*l Îä:i:i Revenue
ff'åi"ri: revenu Direcror/orricer worksheet and 02133e
Ontario Corporations lntormation Act Annual Return1. This worksheet should be completed by charities regislered under the lncome Tax Act (lTA) that are corporations incorporated,
continued, or amalgamated in Ontario and subject to the Ontario Corporations Act (CA). Parts 1 to 7 of this worksheet constitute an'Ontario Corporations Information Acf Annual Return form under the Ontario Corporations lnformation Acf (ClA). All charities mustcomplete Form T1235, Directors/Trustees and Like Officials Worksheet,
2. lt is the corporation's responsibility to ensure that the information shown on the Ontario Ministry of Government Services (MGS)public record is accurate and up to date.
3. Note: To make changes to the address information in Part 2, Parl5 and Part 7 the Street name field musl be completed. CompleteParts 2 to 4. Comþlete Parts 5 to 7 only to report changes in the information recorded on the MGS public record.
4. Please read the pre-printed information on all of the pages carefully. This was the information shown on the MGS public record at thetime it was prepared.
5. ln accordance with the ClA, this worksheet must set out the required information for the corporation as of the date of delivery. TheMGS considers this worksheet delivered on the date that it is filed with the CRA, together with the T3010. A completed worksheetmust be delivered within six (6) months after the end of the corporation's fiscal year-end.
6. This worksheet contains information collected under the authority of both the ITA and the ClA, The information collected underParts 1 to 7 is collected solely for the purposes of the ClA. The information collected for the purposes of the CIA will be transmittedto the MGS for the purpose of recording the information on the public record maintained by the MGS.
Part'l - ldentificationlf the name, date, or Ontario Corporation Number set out in boxes 700 lo7O2 is incorrect for any reasonr do not complete lhisworksheet; you must complete Form RC232, Ontario Corporations lnformation Act Annual Return. To find Form RC232, go towww.cra.gc.ca/charities and select "Charities-related forms and publications".
Parl2 - Head or reg¡stered office address: (P.O. box alone is not sufficient)Please choose one of the following:
flfn" head or registered office address shown below ¡s correct. (go to Part 3)
f] fn" corporation's correct head or registered oftice address is as follows: (set out in full)
Part 3 - Change identifierHave there been any changes in the information most recently filed for the public record maintained by the MGS with respectto names, addresses for service, and the date elected/appointed and date ceased for the directors and five most seniorofficers, or the corporation's mailing address or language of preference?
lf there have been no changes, tick this box and complete Part 4 Certification. lf there are changes, leave this box blank,complete Parts 5 to 7 as applicable, and then go to Part 4 Certification.
Name of corporation (exact¡y as shown on the MGS public record)
CHATHAM.KENT HOSPIGE FOUNDATIONreel
Date of incorporationor amalgamation,wh¡chever ¡s lhe mostrecent
Year Month Day
2015-03-20
zgll Ontario Corporat¡onNumber (OCN)
001 931 670
JODI MARONEY34 WELLINGTON ST E.
CHATHAM ONCA N7M 3N7
Care of (if appllcable)
Street name / Rural Route / Lot and concession number Suite numberSlreet number
Addit¡onal address informat¡on
Country Postal /zip codetown, etc.)708
Canadä, (Vous pouvez obtenk ce formulalre en français à www.arc.cra.gc.ca ou au 1-888-892-5667.) RC232-WSX E (12)
Part4 - CertificationI certify that all information set out in this Ontario Corporations lnformation Acf Annual Relurn is true, correct and complete
712 /Tl nnop¿cl -'l;.o T713 714Last name First name Middle name(s)
I am a: (tick the appropriate box below)
715 Director Officer lX Otn"r individual having knowledge of the affairs of the corporation
Note: Completing ttre certification section is mandatory. Sections 13 and 14 of the Ontario Corporations lnformation Act providepenalties for making false or misleading stalements or omissions.
Part5-Mailingaddress
Tick only one of the following boxes:
Do not show a mailing address on the MGS public record.
Xl fn" corporation's mailing address is the same as the head or registered office address in Part 2 of this worksheet.
The corporalion's complete mailing address is as follows:
Part 6 - Language of preferencelf there has been a change to the language of preference, tick the appropriatebox below. This is the language of preference recorded on the MGS publicrecord for communication with the corporation.
726 l-l Enstish French
Parl 7 - Director/Officer lnformationlf there are any changes to the address information for the individual shown, complete boxes 727 lo 737 . To reportchanges to date elected/appointed and/or date ceased for the individual shown in ParT 7 , complete this part as follows:1 . Director: lf the individual named in Part 7 is a Director (or must be reported ceased as a Director), complete the applicable
boxes 738 to 739,
2. Officer: lf the individual named in Part 7 is one of the corporation's five most senior Officers (or must be reported ceasedin an Officer position), complete the applicable boxes 740 lo 785.
3. Director and Officer: lf the individual named in Part 7 is a Director and one of the corporation's five most senior Officers(or must be reported ceased in these position(s)), complete the applicable boxes from 738 to 785. lf a ceased date isreported, ensure that the original appointed/elected date is also provided in the corresponding box.
4. The corporation is required lo show information on the MGS public record for all of its Directors and a maximum of its fivemost senior officers. lf the MGS public record information shows more than five officer positíons, report ceased dates (andthe original appointed/elected date) for all except the corporation's five most senior Officer positions.
5. Photocopy the attached worksheet and compete ParlT tor each additional individual for whom Director/Officer informationchanges are being made,
6. To report changes to the name of a directoriofficer, enter a ceased date (and the original appointed/elected date) for alldirector/officer positions shown for that individual, and complete a blank Part 7 with the correct director/officer infbrmation.To report changes to both the address and date elected/appointed, set out the correct address and the correctelected/appointed date. Then complete a blank Part 7 ceasing the incorrect position.
34 WELLINGTON ST E.
CHATHAM ONCA N7M 3N7
6
Care of (if applicable)
Slreet number Street name / Rural Route / Lot and concession number Suite number719
Additional address information
glMuniciOality (city, town, etc.)älProvince/State
lzl lcountrv
Postal /Zip code
02L340
Name and
Part 7 - Director/Officer information - (continued)
for service must be com in full (P.O.Box alone is not sufficient)
Please ensure you have completed the Certif¡cation ¡n Part 4 of this worksheet.
14214 TURIN LINE
THAMESVILLE ONCA NOP 2KO
729727 728 First name
DI
Middle name(s)
EARNEY
Last name
731730 Streel name / Rural Route / Lot and concession number Suite numberSlreet number
733
737734 736 Postal /Zip codeMunicipality (city, town, etc.) Province/State Country
