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CANDIDATE NOMINATION PACKAGE
Ma¡lng ð dlfleren(e .logelher
C1
-
Candidate Cover Sheet and Checklist Form
PLEASE PRINT IN BLOCK LETTERS
SECTION A
FIRST
CANDIDATE'S TAST NAME
MIDDLE NAME(S)
NAME
HIKT
tlt ct<s
NAME OF OFFICE FOR WHICH CANDIDATE IS SEEKING ELECTION
ELECTORAL AREA DI RECTOR
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...ri't
SECTION B
This nomination package includes the following completed forms, appointments, consents and declarations
¿Á ./C:2 - Nomination
Documents
Ø Cg - Other lnformation Provided by Candidate
Appointment of Candidate Financial Agent (if Candidate is not acting as own Financial
lrOAppo¡ntment of Candidate official Agent (if applicable)
lrt-
ñ
Agent)
-Appo¡ntment of Candidate Scrutineer (if applicable)
Statement of Disclosure: Financial Disclosure Act (required under the Financial Disclosure Act)
CRD EXECUTIVE OFFICE
Received
OCT
0I
20ttr
D¡sclaimer: Allattempts have been made to ensure the accuracy of the forms contained ìnthe Candidate Nomination Packagehowever the forms are not a substitute for provinctal legrslation and/or regulations-
the latest consolidation of provincial statutes at BC Laws (www bclaws.ca)
for applicable election-related provisions and requirements-
Please refer d¡rectly to
ORIGINAL- Câp¡tal Regional D¡str¡ct
PLEASE KEEP A COPY FOR YOUR RECORDS
c1-PageLof1
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CANDIDATE NOMINATION PACKAGE
Making ô dlfl er.nce.,rogelhêr
C2 - Nomination Documents
PLEASE PRINT IN BLOCK LETTERS
ËiTr:i:TLI.", o
sart spring rstand or
E southern
Gutr tstands ELEcToRAL AREA
We, the following electors of the above named jurisdiction, hereby nominete
FIRST
NOMINEE'S LAST NAME
MIDDLE NAME(S)
NAME
e/( s
Òw/)eb
USUAL NAME OF PERSON NOMINATED IF DIFFERENT FROM ABOVE AND PREFERRED BY THÊ PERSON NOMINATED TO APPEAR ON THE BALLOT
RE5 IDE
'ze
z,
Soo
JF
ccq
POSTAL CODE
CITY/TOWN
DIFFERENT FROM RESIDENTIALADDRESS
(STREETADDRESS/PO BOX NUM BER)
MAILING ADDRESS
POSTAL CODE
crTY/TOWN
NTIAL ADD RESS (STREET ADD RESS)
As a Candidate for the office of:
DIRECTOR
úu"n
de Fuca,
E
salt Spring lsland or
E
Southern Gulf lslands
ELECTORAL AREA
Each of us
1.
2.
3.
4.
5.
ls
affirmS that to the best of our knowledge, the above named person nominated for office:
or will be on general voting day for the election, 18 years of age or older.
ls a Canadian
citizen.
Has been a resident of British Columbia, as determined in accordance with section 52 of the LocalGovernment Act,
for the past six months immediately preceding today's date.
ls not disqualified under th e Locol Government Act, or any other enactment from being nominated for, being elected
to or holding the office, or is not otherwise disqualified by law.
ls
notsubjectto any of the disqualifications setoutin sect¡on 66(2) of the LocalGovernment Act.
NOMINATOR'S NAME (FIRsT, MIDDLE AND LAST NAMES)
Dorot],v|" /'Ð
r-t )
le<
RESIDENTIAL ADDRESS (CITY/TOWN, SlREET ADDRESS, POSTAL CODE)
NOMINATOR'S NAME (FIRST, MIDDLE AND LAST NAMES)
A./aLL.4ZÊ- A
IF
NOMINATING A5 A RESIDENT ELECTOR
2qzz
PROPERTY ADDRESS
IF
(CITY/TOWN, STREET ADDRE55, POSTAL CODE)
q 7-
sq
NOMINATING AS A NON.RESIDENT PROPERTY ELECTOR
v
NOMINATOR'S
D
tQdâtAJs'¿ïh/ R P
(CITY/TOWN, STREET ADDRESS, POSTAL CODE)
NOMINATING A5 A NON-RESIDENT PROPERTY ELECTOR
PROPERTY ADDRESS
IF
11?2 olq
NOMINATOR'S SIGNATURE
4/^I
Vn t-| L ê S
RESIDENTIAL ADDRESS (CITY/TOWN, STREET ADDRESS, POSTAL CODE)
?/--
consent to the above nom¡nation for office
DATE: (YYYY
/ MM /
2ot+
ORIGINAL
- Cap¡tal Regional Distr¡ct
PLEASE KEEP A COPY FOR YOUR RECORDS
c2-PaEe1 oÍ2
DD)
/to
/oV
Th¡s
form
is avaìlable
for public ¡nspection
cr¿fl
Making ð dìlerene
CANDIDATE NOMINATION PACKAGE
.togëther
C2 - Nomination Documents
PLEASE PRINT IN BLOCK LETTERS
I do solemnly declare as follows:
1. lamqualifiedundersection66oftheLocalGovernmentActtobenominated,electedandtoholdtheofficeof
DIRECTOR of the
dn"n
2.
3.
4.
I am
de Fuca,
E
salt Spring lsland or
E
Southern Gulf lslands ELECTORAL AREA
or wÌll be on general voting day for the election, 18 years of age or older.
I am a Canadian c¡tizen.
I
have been a resident of British Columbia, as determined in accordance with section 52 of the Local Government Act,
s¡x months immediately preceding today's date.
for the past
5.
6.
7.
8.
I am in no way disqualified by the Loca{ Government Act, or any other enactment from being nominated for,
being elected to or holding the office, or be otherwise disqualified by law.
To
the best of my knowledge, the information provided in these nomination documents
is
true.
I
fully ¡ntend to accept the office if elected.
I
am aware of and understand the requirements and restrictions of the Locol Elections Campaign Financíng Act and
to comply with those reguírements and restrictions.
I fully intend
NOM INEE'SSIGNATURE
DECLARED BEFORE ME:
AT: (LOCATION)
l-7
EF
OFFICER
OR DEPUTY CHIEF ELECTION OFFICER OR COMMIS5IONER
W c'tagl *, ßc
I am
DATE: (YYYY
acting as my own Financial Agent
I have
Nominee's Signature
- Capital Reg¡onal Distr¡ct
PLEASE KEEP A COPY FOR YOUR RECORDS
DD)
2-t+ /to/oP
?2%
ORIGINAL
/ MM /
FOR TAKING AFFIDAVITS FOR BRITIsH COLUMBIA
appointed as my Financial Agent
Financial Agent's Name (lf Applicable)
c2-P¿ge2of2
This
form
is available
for public inspect¡on
cr¿rl
Mak¡ng ð dlflerè..e
CANDIDATE NOMINAÏION PACKAGE
logelher
C3
-
Other lnformation Provided by Candidate
PLEASE PRINT IN BLOCK LETTERS
Office for which individual is a nominee
POStTtON
DIRECTOR
üär:HÏLl.", o salt spring tslanil or E Southern Gulf tstands
of the
ELECTORAL AREA
NOMINEE'S LAST NAME
FIRST
ilt-kt
NAME
MIDDLE NAME(5)
/7//¿E
E-/at êrt
D
USUAL NAME OF PERSON NOMINATED IF DIFFERENT FROM ABOVE AND PREFERRED BY THE PERSON NOMINATED TO APPEAR ON THE BALLOT
rú
tke
,4rc/¿;
MAILING ADDRES5 (STREETADDRESS/PO BOX NUMBER)
AS PROVIDED IN THE NOMINATION DOCUMENTS
crTY/TOWN
ADDRESS FOR SERVICE (STREET ADDRESS OR EMAIL ADDRESS)
ctTY/TOWN
POSTAL CODE
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TELEPHONE NUMBER
POSTAL CODE
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EMAIL ADDRESS (IF AVAILABLE)
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Fo
Q AFbq?Aus Cove_gúfFSTfÉ¡sü Se
Additional Addresses for Service lnforrr¡âtion
YN
OPTIONAL
MAILING ADDRESS (STREETADDRESS/PO BOX NUMBER)
IF EMAIL WAS PROVIDED AS ADDRESS FOR SERVICE
CITY/TOWN
FAX NUMBER
EMAIL ADDRESS
IF MAILING ADDRESS WAS PROVIDED AS ADDRESS FOR SERVICE
POSTAL CODE
NAME OF ELECTOR ORGANIZATION ENDORSING THE CANDIDATE (IF APPLICABLE)
n
tam acting as my own Financial Agent
Please ensure
ORIGINAL- Cãp¡tal Reg¡onal D¡str¡ct
PLEASE KEEP A COPY FOR YOUR'RECORDS
I am not act¡ng as my own Financial Agent
that name and mailing address information is the same as that
entered on FORM C2 - NOMINATION DOCUMENTS
C3-Pêge1ofL
Thìs
form wìll be provided to Elections
BC
CJ¿T]
CANDIDATE NOMINATION PACKAGE
- Appointment
C4
of Candidate Financial Agent
PLEASE PRINT IN BLOCK LEÏTERS
CANDIDATE'S LAS-| NAME
FIRST NAME
MIDDLE NAME(5)
tTte
,4.k-s
POStTtON
JURISDICTION
DIRECTOR
E
uan de Fuca, E Salt Spring lsland or
Gulf lslands ELECTORAL AREA
South
I hereby appornt as my Financial Agent for the
GENERAL VoTING DATE: (YYYY/MM/DD)
2OL4/]-1,/1,s
General Local Election
By-Election
FINANCIAL AGENT'S LAST NAME
FIRST NAME
MIDDLE NAME(S)
MAILING ADDRESS (STREET ADDRESS/PO BOX NUMBER)
crTY/TOWN
POSTAL CODE
TELEPHONE NUMBER
EMAIL ADDRESS (IF AVAILABLE)
EFFECTIVE DATE OF APPOINTMENT:
(YYYY
/
MM
/
DD)
DATE: (YYYY
CANDIDATE'5 SIGNATURE
I
/
MM
/
DD)
hereby consent to act as the Financial Agent for the above named Candidate for the
GENERAL VOTING DATE: (YYYY/M
tvtloo)'
201,4/1,!lLs
FINANCIAL AGENT ADDRESS FOR
(STREET ADDRESS OR EMAIL ADDRESS)
General Local Election
By-Election
ctTY/TOWN
PO5TAL CODE
MAILING ADDRESS (STREETADDRESS/PO BOX N UMBER)
IF EMAIL WAS PROVIDED AS ADDRESS FOR SERVICE
crTY/TOWN
POSTAL CODE
FAX NUMBER
EMAIL ADDRESS
IF MAILING ADDRESS WAS PROVIDED AS ADDRESS FOR SERVICE
FINANCIAL AGENT'S SIGNATURE
DATE: (YYYY
Add¡t¡onal Addresses for Service tnfo¡'r¡¡atíon
ORIGINAL - For candidate's records
PROVIDE A COPY 7O THE CAPITAL REGIONAL DISTRICT
C4- Page 1 of 1
/ MM /
DD)
Th¡s
form w¡ll be provided to Elections
BC
CT¿I]
CANDIDATE NOMINATION PACKAGE
Mak¡ng. dlfereñcê. toqerher
C5
- Appointment of Candidate
nt
Official
PLEASE PRINT IN BLOCK LETTËRS
CANDIDATE'S LAST NAME
FIRST
MIDDLE NAME(S)
NAME
Juan de Fuca, E Salt Spring lsland or
rn Gulf lslands ELECTORAL AREA
POStTTON
[]So
DI RECTOR
I
hereby appoint as my Official Agent for the:
GENERAL VoTING DATE: (YYYY/MM/DD)
2Or4/tTl1.s
OFFICIAL AGENT'S LAST NAME
FIRST
MAILING ADDRESS (STREET ADDRESS/PO BOX NUMBER)
I hereby delegate to the a
CANDIDATE'S SIGNATURE
ORIGINAL
-
Cap¡tal Regional Distr¡ct
PLEASE KEEP A COPY FOR YOUR RECORDS
By-Election
General Local Election
NAME
MIDDLE NAME(S)
clTY/TOWN
POSTAL CODE
med official agent the authority to appoint scrutineers
DATE: (YYYY
C5-Page1of1
/
MM
/
DD)
This form is not available for public inspect¡on
cr¿rl
Mõk¡ng ô dlferen(e
CANDIDATE NOMINATION PACKAGE
logether
C6
-
Appointment of Candidate Scrutineer
PLEASE PRINT IN BLOCK LETTERS
FIRST NAME
s
MIDDLE NAME(S)
POStTtON
IURISDICTION
DIRECTOR
E
uan de Fuca,
E
Salt Spring lsland or
rn Gulf lslands ELECTORAL AREA
Sout
I hereby appoint as my Scrutineer for the:
GENERAL VoTING DATEr (YYYY/MM/DD)
General Local Election
2OL4/1J/1,s
By-election
SCRUTINEER'S LAST NAME
FIRST NAME
MIDDLE NAME(S)
MAILING ADDRESS (STREET ADDRESS/PO BOX NUMBER)
crTY/TOWN
POSTAL CODE
CANDIDATE'S SIGNATURE
DATE: (YYYY
When appointing more than
ORIGINAL- Capital Regional D¡str¡ct
PLEASE KEEP A COPY FOR YOUR RECORDS
/
MM
/
DD)
e Scrutineer, please attach additional appointment sheets as necessary
C6-Page1of1
Th¡s form is not available
for public inspect¡on
t"ËJ
Statement
RITISH
cBLUMBIA
of Disclosure
Financial Disclosure Act
You must complete a Statement of Disclosure form if you are:
a nominee for election to provincial or local government office*, as a school trustee or as a director of a francophone
education authority
an elected local government official
an elected school trustee, or a director of a francophone education authority
an employee designated by a local government, a francophone education authority or the board of a school district
a public employee designated by the Lieutenant Governor in Council
*("local government" includes municipalities, regional districts and the lslands Trust)
Form and Fact Sheets:
This form, Statement of Disclosure, can be found on the B.C. Government Web site: wvvw gov bc ca [type 'Statement of
Disclosure' in the search barl. The form can be printed and completed by hand, or it can be completed at your computer then
printed. lf you do complete the form at your computer, you will not be able to save it so please ensure you have printed the
completed form before exiting the program. There are also important fact sheets on the Financíal Disclosure Act to accompany
this form on the Web site:
. Fact Sheet for those accepting nomination as a municipal official ltype '4G04003-a' in the search bar]
. Fact Sheet for those accepting nomination as member of the Legislative Assembly in B C.
[type 'AG04003-b' in the search bar]
Who has access to the informat¡on on this form?
The Financial Disclosure,4cf requires you to disclose assets, liabilities and sources of income. Undersection 6 (1)of theAct,
statements of disclosure filed by nominees or municipal officials are available for public inspection during normal business hours
Statements filed by designated employees are not routinely available for public inspection lf you have questions about this
form, please contact your solicitor or your political party's legal counsel.
What is a trustee?
-
s. 5 (2)
ln the following questions the term "trustee" does not mean school trustee or lslands Trusttrustee. Under the Financial
Disclosure Act a trustee:
holds a share in a corporation or an interest in land for your benefìt, or is liable under the lncome Tax Act (Canada)
to pay income tax on income received on the share or land interest
has an agreement entitling him or her to acquire an interest in land for your benefit
.
.
name
Person making disclosure
Street, rural route, post office
box;
City
first & m¡ddle name(s)
Ê
5
;
3ot
¿erL
S*n l¿e
Province:
Level of government that ap lies to
you:
î3<
Postal Code
4/
Lg
I provincial t"government
i--, school board/frahcophone ed ucatio n authority
lf sections do not provide enough space, attach a separafe sheef to continue.
Assets -s.3(a)
List the name of each corporation in which you hold one or more shares, including shares held by a trustee on your behalf:
OL
rn
US
+
J'
Liabilities
-s. 3 (e)
List all creditors to whom you owe a debt Do not include residential property debt (mortgage, lease or agreement for
sale), money borrowed for household or personal living expenses, or any assets you hold in trust for another person:
creditor's name(s)
creditor's address(es,)
lncome -s.3 (b-d)
List each of the businesses and organizations from which you receive financial remuneration for yourservices and
identify your capacity as owner, part-owner, employee, trustee, partner or other (e g director of a company or
society).
.
.
Provincial nominees and designated employees must list all sources of income in the province.
Local government officials, school board officials, francophone education authority directors and designated employees must
list only income sources within the regional district that includes the municipality, local trust area or school district for which the
offlcial is elected or nominated, or where the erhployee holds the designated position
your
capacity
name(s) of busrness(es)/organization(s)
?o' 5 D(o/t
o
Én1 u
¿-S
ED
Real Property-s.
3 (r)
List the legal description and address of all land in which you, or a trustee acting on your behalf, own an interest
or have an agreement which entitles you to obtain an interest Do not include your personal residence
Provincial nominees and designated employees must list all applicable land holdings in the province
.
.
Local government offìcials, school board officials, francophone education authority directors and designated employees must
list only applicable land holdings within the regional district that includes the municipality, local trust area or school district for
which the official is elected or nominated, or where the employee holds the designated position
legal description(s)
address(es)
i/,rrr:Z (l:
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ln
s
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2
Corporate Assets - s. 5
Do you individually, ortogetherwith yourspouse, child, brother, sister, mother orfather, own shares in a corporation which
total more than 30% of votes for electing directors? (lnclude shares held by a trustee on your behalf, but not shares you hold
by way of security,) -' no Vyes
lf yes, please list the following information below & continue on a separate sheet as necessary:
.
.
.
.
.
the name of each corporation and all of its subsidiaries
in general terms, the type of business the corporation and its subsidiaries normally conduct
a description and address of land in which the corporation, its subsidiaries or a trustee acting for the corporation, own an
interest, or have an agreement entitling any of them to acquire an interest
alistofcreditorsofthecorporation,includingitssubsidiaries Youneednotincludedebtsof lessthan$5,000payablein90
days
a list of any other corporations in which the corporation, including its subsidiaries or trustees acting for them, holds one or
more shares.
L
\l-lrnpus l/ e*'lur¿e s Uor<t A12 2" S Ì+êeÊs 1A
Ftskpc )-a/ 5e-
%2
signature of person making disclosure
date
Where to send this completed disclosure form:
* Local government officials:
... to your local chief election officer
with your nomination papers, and
... to the officer responsible for corporate administration
. between the 1st and 15th ofJanuary ofeach year you hold offìce, and
. by the 1Sth of the month after you leave office
.¡. School board trustees/ Francophone Education Authority directors:
... to the secretary treasurer or chief executive officer of the authority
. with your nomination papers, and
. between the I st and 5th of January of each year you hold office, and
. by the 1Sth of the month after you leave office
{. Nominees for provincial office:
. with your nomination papers lf elected you will be advised of further disclosure requirements under the
1
Members' Conflict of lnterest Act.
.¡. Designated Employees:
... to the appropriate disclosure clerk (local government officer responsible for
corporate administration, secretary treasurer, or Clerk of the Legislative Assembly)
. by the 1Sth of the month you become a designated employee, and
. between the l st and 1sth of January of each year you are employed, and
. by the '1Sth of the month after you leave your position
#AG04003 0V2004
|
CRD
08/2014
3
tslandsTrust
Mak¡ng a difference...together
2014 GENERAL LOCAL ELECTION
CONSENT OF DISCLOSURE OF PERSONAL INFORMATION
/<
Name of Candidate:
J
Candidate for the Office of:
Capital Regional District Electoral Area Director
lslands Trust Local Trustee
DIRECTOR of the
LOCAL TRUSTEE of
tri Galiano lsland Local TrustArea
E Mayne lsland Local TrustArea
E N. Pender lsland Local Trust Area
E S. Pender lsland Local Trust Area
E Salt Spring lsland LocalTrust Area
E Saturna lsland Local Trust Area
E Juan de Fuca Electoral Area
E Salt Spring lsland Electoral Area
E Southern Gulf lslands Electoral Area
ln accordance with the Freedom of Information and Protection of Privacy Ácl I hereby authorize election sfaff 1o
with
include on the Cap1al Regional District website and make available to any person the following information
respect to my candidacy
Address:
for
ty
@
elected office:
L¿u-
o
L oc3
le-
Telephone Numbe(s) (lndicate if home, business or campaign office):
Zfr
z(L
{Ko¿
E-mail address
Website: address
social Media Addresses (Facebook /Twitter/Google+/Flicker/Linkedl
n)
4rt t
Signature of Nominated
Candidate
;2at7'
Date
personal information on this form is collected solely for the purposes authorized by the Local Govemment Act and
is subject to disclosure in accordance with lhe Freedom' of lnformation and Protection of Privacy Acf. The
information will be ,""0 fot authorizing candidate information to be placed on the Capital Regional District website
or made available to any person forlne general local election. Questions regarding this collection of personal
information should be dirécied to the Chief Election Officer or Deputy Chief Election Officer at:
Capital Regional District
625 Fisgard Street
Victoria, BC, V8W 1R7
I 580943
T:250.360.3129
F:250.360.3130
www.crd.bc.ca