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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. 1. CHECK APPROPRIATE BOX(ES): /tn�F��/CFO -�� CC�4 � C/o�kevdsi,. OFFICE USE: ONLY ® Initial Filing of Form Re -filing to Change: L. Treasurer/Deputy ❑ Depository ❑ Office ❑ Party 2. Name of V Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, ap ttk Kk W 0 t`I l, b (LL t I+OA S code) (ta 3 V S PO-7 (_S„rk 1.Q5 4. Telephone 5. E-mail address SE $ 14 S ftL4^o PE 3�_j S $ 5-t7i/ 1-PgVm10 (ot4jC14ST , fir 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if /+ / applicable: Src (S A5 i f WAJ L c 11 (C>UNL+ L ❑ 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 0 Write-in © No Party Affiliation C] 0 A Party candidate, 9. 1 have appointed the following person to act as my ® Campaign Treasurer ❑ Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer 14, 11. Mailing Address 12, Telephone (VLS VS ((-177)'It35b-1 13. City14. County, 15. State 16. Zip Code 17. E-mail addre ty p ,*s St t aSi tt4� t�ttt,1 Rttu �i— 370 So �Jlw,to t? C aOAti46T, N'- r 18.1 have designated the following bank as my © Primary Depository Q Secondary Depository 19. Name of Bank 20. Address T,"r (_ &MIc I 56Avks-frWN slurD 21. City 22. County C 23. State 224.. Zip Code r✓a.Lj --'C-2 tAJ �llt'C/ I fL- 157-g5 2 UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FA_CI5-ST IN IT ARE TRUE. 25. Date ZZ ( 26. Sign re of Cardida 27. Treasurer's Acceptance of Appointment (fill in the blanks anct�check the appropriate block) 1, JkiMt £ v` 1 • C I LLi td t^^S do hereby accept the appointment (Please Print or Type Name) designated above as: ® Campaign Treasurer u y asurer. x _ Date Signature of a paign Treasurer or Deputy Treasurer DS•DE 9 (Rev.10/10) Rule 1S-2.0001, F.A.C.