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CAMPAIGN FINANCE STATEMENT - Mae Khamissa - 20230202Ontario Ministry of Municipal Affairs Financial Statement — and Housing Auditor's Report 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 immediately paid to the clerk who is responsible for the conduct of the election. YYYY MM DID YYYY MM DID For the campaign period from (day clerk received nomination) r, T, _1�)_ I O �, ( to I 1 j ® Initial filing reflecting finances from start of campaign to December 31 (or 45 days after voting day in a by-election) Supplementary filing reflecting finances from start of campaign to end of extended campaign period Box A: Name of Candidate and Office Candidate's name as shown on the ballot Last Name or Single Name Given Name(s) Office for Which the Candidate Sought Election Ward Name or Number (if any) Municipality — 13 LO i Lit Spending Limit I Contribution Limit General Parties and Other Expressions of Appreciation Contributions from Candidate and Spouse $ 11182o.40 $ 1, 192.Gy $ 6,G054•S© I did not accept any contributions or incur any expenses. (Complete Boxes A and B only) Box B: Declaration , declare that to the best of m 1, ��A i_l Z- +r% �1 +"1'1, S S �� dlY knowledge and belief that these financial statements and attached supporting schedules are true and correct. Date Filed (yyyy/mmldd) I Time Filed v9. Tu, P 3 Date (yyyylmmldd) Initial of Candidate or Agent (if filed in person) Signatur of Clerk or Designate n r'O 9503P (2022/04) © Queen's Printer for Ontario, 2022 Disponible en fran�ais Page 1 of 7 Box C: Statement of Campaign Income and Expenses LOAN Name of bank or recognized lending institution 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 earned by campaign bank account Other (provide full details) 2. 3. 4. 5. 6. Total Campaign Income (Do not include loan) + $QJ.�1 + $ "-- + $ EXPENSES (Note: Include the value of contributions of goods and services) 1. Expenses subject to general spending limit Inventory from previous campaign used in this campaign (list details in Table 2 of Schedule 1) Advertising Brochures/flyers Signs (including sign deposit) Meetings hosted Office expenses incurred until voting day Phone and/or internet expenses incurred until voting day Salaries, benefits, honoraria, professional fees incurred until voting day Bank charges incurred until voting day Interest charged on loan until voting day Other (provide full details) 1. + $ CJ + $ PLYA 1 �111 + $ . 0 + $ + $ +$ 1 00 2. + $ 3. + $ 4. + $ 5. + $ 6. + $ Total Expenses subjectto general spending limit = $ C2 T 2. Expenses subject to spending limit for parties and other expressions of appreciation 1 Amount borrowed C1 9503P (2022/04) Page 2 of 7 2. +$ 3. + $ 4. + $ 5. + $ Total Expenses subject to spending limit for parties and other expressions of appreciation = $ ® C3 3. 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 + $ r Expenses related to controverted election + $ Expenses related to compliance audit + $ r " Expenses related to candidate's disability (provide full details) 1. + $ 2. + $ 3. + $ 4. + $ 5. + $ Other (provide full details) 1. + $ 2. + $ 3. + $ 4. + $ 5. + $ Total Expenses not subject to spending limits = $ — "� 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) + $ D1 If there is a surplus, deduct any refund of candidate's or spouse's contributions to the campaign — $ Surplus (or deficit) for the campaign �? _ $ D2 If line D2 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(2022104) Page 3 of 7 Schedule 1 - Contributions Part I — Summary of Contributions Contributions in money from candidate and spouse + $ 1SS5-. Contributions in goods and services from candidate and spouse (include value listed in Table 1 and Table 2) + $ 0 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). + $ 0 Total value of contributions exceeding $100 per contributor (from line 1 B; list details in Table 3 and Table 4) • 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). + $ 00 Less: Ineligible contributions paid 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) _ $ j 1 1A Part II — Contributions from candidate or spouse Table 1: Contributions in goods or services Description of Goods or Services Date Received Value ($) (YYYy/mm/dd) Total ❑ Additional information is listed on separate supplementary attachment, if completed manually. Table 2: Inventory of campaign goods and materials from previous municipal campaign used in this campaign (Note: Value must be recorded as a contribution from the candidate and as an expense.) Description Date Acquired (yyyy/mm/dd) Supplier Quantity Current Market Value ($) fr' Total ❑ Additional information is listed on separate supplementary attachment, if completed manually. Part III — Contributions exceeding $100 per contributor — individuals other than candidate or spouse 9503P (2022/04) Page 4 of 7 Table 3: Monetary contributions from individuals other than candidate or spouse Name Full Address Date Received (yyyy/mm/dd) Amount Received ($) Amount Returned to Contributor or Paid to Clerk ($) d < uC\AV, D �- iVnIF-sft5 \awto —er- u. zo�z* I o ry L I)C3 �7 TZY�iv L � ,�wraiylX f oR--AOm U •5 A6 Total ❑ Additional information is listed on separate supplementary attachment, if completed manually. Table 4: Contributions in goods or services from individuals other than candidate or spouse (Note: Must also be recorded as Expenses in Box C.) Name Full Address Description of Goods Date Received Value ($) or Services (yyyy/mm/dd) Total Additional information is listed on separate supplementary attachment, if completed manually. Total for Part III — Contributions exceeding $100 per contributor (Add totals from Table 3 and Table 4 and record the total in Part 1 — Summary of Contributions) $ 1B 9503P (2022104) Page 5 of 7 Schedule 2 - Fundraising Events and Activities Complete a separate schedule for each event or activity held. Additional schedule(s) attached, if completed manually. Fundraising EventlActivity 1 Description of fundraising eventlactivity Date of eventlactivity (yyyy/mm/dd) Part. I - Ticket revenue Admission charge (per person) $ 2A (If there are a range of ticket prices, attach complete breakdown of all ticket sales) Number of tickets sold x 2B Total Part I (2A X 2B) (include in Part I of Schedule 1) _ $ Part II - Other revenue deemed a contribution Provide details (e.g., revenue from goods sold in excess of fair market value) 1. + $ 2. + $ 3. +$ 4. +$ 5. + $ Total Part 11 (include in Part I of Schedule 1) Part III - Other revenue not deemed a contribution Provide details (e.g., contribution of $25 or less; goods or services sold for $25 or less) 1. + $ 2. e + $ 3. - + $ 4. + $ 5. + $ Total Part III (include under Income in Box C) Part IV - Expenses related to fundraising event or activity Provide details 1. + $ 2. + $ 3. + $ 4. + $ 5. + $ Total Part IV Expenses (include under Expenses in Box C) 9503P (2022104) Page 6 of 7 Auditor's Report — MunicipalElections 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 Municipality Date (yyyy/mm/dd) Contact Information Last Name or Single Name Given Name(s) Licence Number Address Suite/Unit Number Street Number Street Name Municipality Province Postal Code Telephone Number Email Address The report must be done in accordance with generally accepted auditing standards and must: 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 (2022/04) Page 7 of 7