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APPOINTMENT OF CAMPAIGN TREASURED !//R{
AND DESIGNATION OF CAMPAIGN 2 0
DEPOSITORY FOR CANDIDATES L`ty or Se
(Section 106.021 (1), F.S.) �I`Y Cierk,d�ce
(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
code)
�K� C �1,00
4 TPlenhnno 5. E-mail address
i Iii 0 @ �i�1P1 L . coy\
^o. Office sought (include district, circuit, group number) 17. If a candidate for a nonpartisan office, check if
n applicable: �I �t%➢v C 1 e ❑ my intent is to run as Write -In candidate.
B. If a candidate fora Partisan office, check block and fill in name of parbj as applicable: My intent is to run as a
® Write -In � No Party Affiliation D Party candidate.
g. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
A (,gIN
11. Mailinn Arin—..
12. Telephone
13. Gty t 14. County 1 tate 17. E -mall address
10^ Zip Code
l�;c�/�,�=.�-vltiva�`�y�IG�
18. 1 have designated the following bank as my Primary Depository ❑ Secondary Depostory
15. dame of Bank 20. Address
21. City 22. County 23. State 24. Zip Code
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 FACT ATED IN IT ARE TRUE.
J5. Dale 1 26. Sig atu of andi ate
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27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
1. \ �--�-;:),j i�\n , do hereby accept the appointment
(Please Print or Type flame)
designated above as: ) Campaign Treasurer ❑ ou Tr asurerf
Lrate Signature of Campaign reasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) -_�� J-__� ^ ~�y� Rule 1S-2.0001, F.A.C.