HomeMy WebLinkAboutDSDE 9 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):
(Q Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy
2. Name of Candidate (in this order: First, Middle, Last)
)di,KtUn `C<- A�'l (fj111[QVU5
4. Telephone 5. Candidate's Voter Registration #:
7713-110 ,(�s3�b l 3 q
(Not required for Qualifying Purposes)
RECEIVED
AUG 15 2023
City Of Sebastian
City Clerk's Offic.,
OFFICE USE ONLY
❑ Depository ❑ Office ❑ Party
3. Address (include post office box or street, city, state,
zip code)
«a3 Us <<
FL. 5A158
(Not required for Qualifying Purposes) • Phonetic spelling for audio ballot: Print name phonelical:y on the line below as you wish it to be pronounced on
the audio ballot as may be used by persons with disabilaies (see Instructions on page 2 of this form):
_A i _AA — Fe —�— ty ��i �- vt4 — M- N - UA
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
. "Fgt Ci a-r ! applicable:
lit l l ❑ My intent is to run as a Write -In candidate.
8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a
❑ Write -In ZNo Party Affiliation ❑
9. 1 have appointed the following person to act as my
10. Name of Treasurer or Deputy Treasurer
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1?. Mailing Address I
(to% u5f I S u4e_ Ar,
16. 1 have designated the following bank as my
Campaign Treasurer
Party candidate.
❑ Deputy Treasurer
I State
1,zty5JrQAi I,4.
Primary Depository ❑
11. Telephone
(779 )715 �
15. Zip Code
3rP58
Secondary Depository
17. Name f Bank
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18. Ad ess
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19. city
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20. County
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21.
State
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22. ip Code
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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
FACTS STATED IN IT
ARE TRUE.
23. Date r / � X Signat a of to
I (5 23
25. Treasurer's!r Acceptance of Appoinant (fill in thelplanks and check the appropriate block)
I, 'Dd VIA. f eJ� L 4 f_ .4) / r-1 ['/ r<?4a� r do hereby accept the appointment
(Please not I Type)Neme)
designated above as: Campaign Treasurer. D4epuTm a surer.
Date SId�rE rpagn Treasurer or Deputy Treasurer
DS-DE 9 (Rev. 07123)
r Rule 1S-2.0001, F.A.C.