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) I
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: ❑
2. Name of Candidate (in this order: First, Middle, Last)
Treasurer/Deputy ❑ Depository
OFFICE USE ONLY
❑ Office ❑ Party
3. Address (include post office box or street, city, state, zip
code) 70 q So r du n i% P_
4. Telephone 5. E-mail address S 64 S �I 6t 1 / L 3�'����
(»suj C�trijil��'I`1Se& o �t�N uLfco.-i
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonDartisan office, check if
C Co vt vt G/ j applicable:
❑ My intent is to run as a Write -In candidate.
8. If a candidate fora partisan office, check block and fill in name of party as applicable: My intent is to run as a
❑ Write -In No Party Affiliation ❑
9. 1 have appointed the following person to act as my
10. Name of Treasurer or Deputy Treasurer
Th cD*Vl t f 6�'e C, --9 P_ ct
11. Mailing Address v
1s3y �sl�-hrd�� Gait -
Campaign Treasurer ❑
Party candidate.
Deputy Treasurer
12. Telephone
( E63 ) Ro 6 -5:; yb/
13. City
��bas i a17
14. County
mcefFq^ X. v&r
15. State
Pc
16. Zip Code
17. E-mail address
-,tv &{6�15-aLi
18. 1 have designated the following bank as my
❑
Primary Depository Secondary Depository
19. Name
City /c,s�i22. County` 23. State C 24. Zip Code
St�catg-r✓ICl�rnn ie�ve✓ / �- 3�-95�
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 TRUE.
25. Date 2266. Signature of C ndidate
5` �f% /�✓
27. Treasurer's Acceptance of Appointment ill in the blanks and check the appropriate block)
's
I. / Ao � u S Ap` V c do herebyt the accept appointment
(Please Print or Type Name RECEIVED
designated above as: � Campaign Treasurers ❑ Depty Treasu r.
X ✓/Lrywas z,4
MAY 111 20L;
-.-Ity Of Seb2a1ian
Date Signature of Campaign Treasurer or Dap4t�CfinelasuWfice
DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.