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HomeMy WebLinkAboutAppt of Treasurer 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. REC'Ewj�D Cl�y of City Clerk, Ian OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): Ea Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office [] Party 2. Name of Candidate (in t Is orde Middle, Last) 3. Address (include post office box or strr t city, state, zip //�� code —7 �+ 7 Q� ��� yam}^ 4. Telephone ' I / 5. E-mail address I (<? 2��lCe'� � \v 6. Office sought (include district, ckduit, group7fumber) 7. If a candidate for a nonaartisan office, check if ( ^ I n 1 applicable: CI���.A ( ) I I r � f 1 My intent is to run as a Write -In candidate. 8. If as candidate fora `artisann office, check blockand 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 © Campaign Treasurer ❑ Deputy Treasurer 10. Name/of Treasurer Deputy Treasurer 1 IOX 11. Mailing Address 12. Telephone 13 dy 14. County 15. ate 16. Zip Code `1 17. E-mail address ^ 18. 1 have designated the following bank as my Primary Depository ❑ Secondary Depository 19. N of Ban 20. Address �A ��'X.c.ST 2�—/�Ity// / 22. County 23. St/�tJg 24. Zip Code; \1�iM1G.C77G bl 7 (lam T UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREgj OR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND TMAT_THE FACTSF&KATED IN IT ARE TRUE. 25. Date 26.WbIe `f/lV 2� X 27. Treasurer's Acceptance /of Appointment (fill itheappropriate block) I, 46 ve I UO 16,A % i�sf7J �)o hereby accept the appointment (Plea rent or Type Name) designated above as: Campaign Treasurer Deputy Treasurer. lz� X S Date � V Ignatur�e f ampalgn Treasurer or Deputy Treasurer DS-DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.