HomeMy WebLinkAboutDSDE9 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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HFri �, 3
Cityof
Cit/ C' Sebas;'
1. CHECK APPROPRIATE BOX(ES):
0 Initial Filing of Form Re -Fling to Change: ❑ Treasurer/Deputy ❑ Depository
2. Name of Candidate (in this order: First, Middle, Last)
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4. Telephone 5. E-mail address
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) 5+.
7. If a candidate for a nonpartisan office, check if
applicable:
�t} cw^C, I ❑ 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 ❑
Party candidate.
9. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
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11. Mailing Address 12. Telephone
itAb ty)pk 4 (7 977
13. City V 14. County 15. State 16. Zip Code 17. E-mail address
so rrV 1:404 RZ'ez TL jZ,4qT7 5qP�Av,,An0_�d6 ,.44
18. 1 have designated the following bank as my X Primary Depository ❑ Secondary Depository
19. Name of Bank 20. Address
21. C' 22. County 23. State 24. Zip Code
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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
26. Signature of Candidate
X X , � .-.
27. TreasureI�jisA cep'/^
t/a�nceof Appointment (fill in the blanks and check the appropriate block)
' QV t k 1 do hereby accept the appointment
(Please Pri or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
20Z� X
ate Si ature�ofCampaign Treasurer or Deputy Treasurer
DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.