HomeMy WebLinkAboutDepository PPOINTMENT 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.
1. CdECK APPROPRIATE BOX(ES):
® Initial Filing of Form Re -filing to Change: ❑
114 Fb
c,
C/ekfe G'1G0 s'1
Ofbe,
Treasurer/Deputy ❑ Depository
2. Name of Candidate (in this order: First, 9 le, La �
COX
4. Telephone 5. E-mail address /
( ?72)a0S-5�l9GPr,flra42, „ten
6. Office sought (include district, circuit, group number)
OFFICE USE ONLY
❑ Office ❑ Party
3. Address (include post office box or street, city, state, zip
code)
&lr-'� r�rAz�
5L'_1,2S 7, � n, Kz- 3�5�'
7. If a candidate for a nonpartisan office, check if
j 1 applicable:
L C ' / 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 ❑ No Party Affiliation ❑
Party candidate.
9. 1 have appointed the following person to act as my ErCampaign Treasurer ❑ Deputy Treasurer
10. SNa a of Treasurer or puty Treasurer
T� �� � la
11. Mailing Address 12. Telephone
o S
13. "City/ 14. C/4unty // 1%6.�Znip Code 17. E-mail address 15. State
S�'�Y79S �i4�• nNJq,.
18. 1 have designated the following bank as my D_�Primary Depository / ❑ Secondary Depository
19Nmeof B nk 20.. Address '%d /
21. City 122. C unty � 23. State `% 24. Zip Cod
SPda.S,�h I1��4 /C'F-E-. 3�9sr1�
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 FACTS STATED IN IT
ARE
STvRU�E.
Sgnatur f25. Date XoCddaate%�-
27. /Treasurer's A cepta[nce of Appointment (fill in the blanks and check the appropriate block)
q V— r /o do hereby accept the appointment
(Please Pri t or Type Name)
designated above as: ampaign Treasurer Deputy Tre ur r.
se/6 k-o ao X � YSSS
Date Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.