HomeMy WebLinkAboutDSDE9DS -DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.
RsCE/V
APPOINTMENT OF CAMPAIGN TREASURER
ED
AND DESIGNATION OF CAMPAIGN
A UG
DEPOSITORY FOR CANDIDATESc
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(Section 106.021(1), F.S.)
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(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
3. Address (include post office box or street, city, state, Zip
,D,+ ml-eYr 9 6�r Z -Z-1 0¢4-ji s
code)
4. Telephone
5. E-mail address
(772- ) '7f 3 �_v?t
0�eo
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
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1,fiLT1 C t -7 C �c L
applicable:
My intent is to run as a Write -In candidate.
8. If a candidate for aap rtisan office, check block and fill in name of party as applicable: My intent is to run as a
❑ Write -In ❑ No Party Affiliation ❑ ^1-4 Party candidate.
9. 1 have appointed the following person to act as my D -Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
,bWM/-eh /_r�5; e L c r
11. Mailing Address r
l(,: 9 Z 3 t1s �f S �� s
12. Telephone
( 7?z- ) pis
13.f ity
14. County
15. State
16. Zip Code
7. E-mail address
[187.1 have designated the following bank as my ❑ Primary Depository ❑ Secondary Depository
19. Name of Bank
I -",A/C � �
20. Address
17037- VS / L�• i
21. Cit�22.
41v I
County
23. State
24. Zip Code
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UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING OR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND T THE FACTS "TED IN IT ARE TRUE.
25. Date
26. Sig ture of C n date
27. Treasurer's Acceptance of Appointment (fill in the bl ks a check the appropriate block)
_
do hereby accept the appointment
(Please Print or Type Name)
designated above as:Ef Campaign Treasurer Deput Treasurer.
X -
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.