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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
EC 20120
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