HomeMy WebLinkAboutDSDE9APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
1C1iECK APPROPRIATE BOX(ES):
YInitial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository
2. N of C ndidate In this order. First Middle, Last)
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4. Telephone 15. E-mail addr ss
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6. Office sought (include district, circuit, roup numb
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RCF -0
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C'm 01 ClerK,, Otiice
C1tY
OFFICE USE ONLY
❑ Office ❑ Party
3. Address (include post office box or street, city, state, zip
code) l}_ �r a
�.basttal�, �1✓
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 a partisan office, check block and fill In name of party as applicable: My intent is to run as a
❑ Write -In J$� No Party Affiliation ❑ Party candidate.
9. 1 have appointed the following person to act as my ?V1 Campaign Treasurer ❑ Deputy Treasurer
10. ame of Treasurer or Deputy Treasurer
11. Mailing Address 12. Telephone
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L 14. County
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15. State
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116. Zip Code
3Z95?
17. E-mail ad ress `(()�
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18. 1 have designated the
following bank as my
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Primary Depository ❑ Secondary Depository
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24. Zip Code
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UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM PINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT CT IN IT ARE TRUE.
25. Date � JI (/� 2fi�gnat C didat9
27. It
Acceptance of Appointment {X in the bl ks an deck the appropriate block)
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Y� �c� do hereby accept the appointment
(Please Pnnt or Type Name)
designated above as: �( Campaign Treasurer as urer.
�I x
Date ig u o ap%�t�i reasurer or epu asurer
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.