HomeMy WebLinkAboutDSDE 9 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.
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OFFICE USE ONLY
j. CrHECK APPROPRIATE BOX(ES):
Ind\ 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
eppost
/office box or street, city, state, zip
L ��LiCSN code) �0�`�
4. Telephone 5. E-mail address Lf 0
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6. Office�soought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, chuck if
�> A .5 i to hJ applicable:
(2: 1 `7 cc>\3k)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 F1 Party candidate
9. 1 have appointed the following person to act as my —Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
11. Mailing Address
13. City
12. Telephone
14. County
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15. State
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I 16. Zip Code
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17. E-mail address
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18. 1 have designated the following bank as my 0 Primary Depository Secondary Depository
19. Name of Bank 20. Address
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21. City 22. County 23. State 24. Zip Code
9ir943T/2�NdPIAI R1VC>2 Fi0P_P1 �L- 3-.)L95c�
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREAS'JRER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
25. Date 26. Signa Ca i&
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27. Treasurer'. of Appointment (fill in the blanks and check the appropriate block)
I, / r i✓ Jj /''//77 0 S Ve-Al- do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Depu asu
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.d
Date ature of mpaign Treasurer or Deputy Treasurer
DS-DE 9 (Rev. 10/10) Rule 1S-2.00111, F.A.C.