HomeMy WebLinkAboutDSDE9 PPOINTMENT OF CAMPAIGN TREASURER �I�R�CF�V�O
AND DESIGNATION OF CAMPAIGN r
DEPOSITORY FOR CANDIDATES C%ry e�j
(Section 106.021(1), F.S.) CryC' �Sb`'Sri?)
(PLEASE PRINT OR TYPE) `r� e�
NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
[A Initial Filing of Form Re -filing to Change: 14 Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, ap
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4. Telephone 5. E-mail address 5 v,'{G <t 5- .z4 S�
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6.Office sought (include district, circuit, grouf) number) 7. If a candidate for a nonpartisan office, check If
S`inq S' `�- iq h I applicable:
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iM I_2.0'e (/ ❑ 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 �T' Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
11. Mailing Address 12. Telephone
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13. City i 14. County 15. State 16. Zip Code L 17. E-mail address
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18. 1 have designated the following bank as my
19. Name of Bank
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21. City 22pp. County
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® Primary Depository Secondary DeposlOry
20. Address
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23. St�t9 12 311 J eCoda
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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. Signatur of Candi
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27. Treasurers Acceptance of Appointment (fill in the bl ks and check the appropriate black)
I, 1 I ( iaV4 Ci , do hereby accept the appointment
(Please Print or Type Name)
designated above as: jy,►, Campaign Treasurer Xofpaign—
TsurerX
Date SignaTreasurerorDeputyTreasurer
DS-DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.