HomeMy WebLinkAboutDS DE 9 PPOINTMENT OF CAMPAIGN TREASURER RECEIVED
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES JUL 1 1014
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE) C City of SebastiaClerk's Office
Y
NOTE: This form must be on file with the filing officer before
opening the campaign account. OFFICE: USE ONLY
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form ❑ Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last): 3. Address (include PO Box or Street, City, State, Zip Code):
Please Print or Type Name)
4. Telephone: 5. Candidate's Voter Registration #: 6. EEma'il Ad1dress:
4011— C44G CC'C(not required for qualifying purposes) O�d �%Q g��t�-GUw�
7. Office Sought (include district, circuit, group, or seat #): 8. f a candidate for a nonpartisan office, check the box
if applicable:
l { ;, o �21t� t!c�t..c'A YI11�PMl..�i El intend to run as a Write -In Candidate.
9. If a candidate t'or partisan office, check t�e box and fill in the name of the party as applicable: I intend to run as a
❑ Write -In Candidate. ❑ No Party Affiliation Candidate. ❑ Party candidate.
10. 1 have appointed the following person to act as my: V Campaign Treasurer ❑ Deputy Treasurer
11. Name of Treasurer or Deputy Treasurer: 12. Telephone: 13. Email Address:
(1�2 )Y73 !&-/Ya rddc�ldG1A�XAQII.coo,
14. Mailing Address: 15, C4y: 16. Sate: 17. Zip Code:
C?C(. Fl,pw^l'At s} ��es� i e-. fq- 32c�5 r,
18. 1 have designated the following bank as my (check appropriate box): []-Primary Depository ❑ Secondary Depository
19. Name of Bank: 20. Address:
p►vC is e. )C_ 193 Y-.)lvQ
21. City: 22. County: 23. State: 24. Zip Code:
t,, Ft- 1hXt !?_+'V•r F4- 524; g-i '
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR THE APPOINTMENT OF THE
CAMPAIGN TREASURER AND DESIGNATION OF THE CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
26. Signature of Cyan l jdidate:
%
25. Date: � � Z /.�O.ZY X ( Frr.� (-F/ �o ,v
(
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate box)
1, 1^l.�1�1�2� v° a J do hereby accept the appointment designated above as:
(Please Print or Type Name)
[ J] finpaign Treasurer. ❑ Deputy Treasurer.
29. Signatur of Campaign Treasurer or Deputy Treasurer
28. Date: I¢-7 (I�� y L V(�
DS-DE 9 (Rev. 09123) /` ((( QQQ Rule 1S-2.0001, F.A.C.