HomeMy WebLinkAboutDSDE9APPOINTMENT OF CAMPAIGN TREASURER R�G'cNED
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.) Mlcy G04{Ic
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(PLEASE PRINT OR TYPE) CAI
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
L. 941ECK APPROPRIATE BOX(ES):
M Initial Filing of Form Re -filing to Change: [-] Treasurer/Deputy C] Depository
2. Name of Candidate (in this order: First, Middle, Last)
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4. Telephone 5. E-mail adddrress
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6. Office sought (include district, circuit, group number)
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OFFICE USE ONLY
[j Office E] Party
3. Address (include post office box or street, city, state, zip
code)
7. If a candidate for a nonpartisan office, check if
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
F] Write -In ❑ No Party Affiliation ® Party candidate.
9. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer
10. `Name of Treasurer or Deputy Treasurer
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11. Mailing Address / 12. Telephone
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13. City &rj14. County 15. State
to 16. Zip Code 117. E-mail address 1
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18. 1 have designated the following bank as my Primary Depository C] Secondary Depository
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21. City
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20. Address
23.,Pate ate 24. Zip Code
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UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE F STA IN IT ARE TRUE.
25. Date 26. Signatur of Candida e
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27. Treasurer's Acceptance of Appointment (fill in the blanks and eck the appropriate block)
1, w� �-P+� k _i _ C—t t_ L__ j %4_%,VL i , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy rea ur
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Date Signature of Campaigpofrreasurer or Deputy Treasurer
DS -DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.