HomeMy WebLinkAboutAdams Pre-Qualifying Docs - DSDE9,84&EligAPPOINTMENT TREASURER
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AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
City 2Qf�
o
C/ C /erk'sbpan
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
X) Initial Filing of Form Re- filing to Change: C] Treasurer /Deputy ❑ Depository ❑ Office F] Party
2. Name of Candidate (in this order: First, Middle, Last)
3. Address (include post office box or street, city, state, zip
Jerome Michael Adams
code)
901 Roseland Rd.,
Sebastian, FL 32958
4. Telephone
5. E -mail address
(772 ) 924 -1259
adams- 12 @att.net
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
Councilmember
applicable:
❑ 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 ❑ No Party Affiliation Party candidate.
9. 1 have appointed the following person to act as my 0 Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
Jerome Adams
11. Mailing Address
12. Telephone
901 Roseland Rd.
( 772 ) 924 -1259
13. City
14. County
15. State
16. Zip Code
17. E -mail address
Sebastian
Indian River
FL
32958
adams- 12 @att.net
18. 1 have designated the following bank as my QX Primary Depository Secondary Depository
19. Name of Bank
20. Address
PNC Bank 1993
Sebastian Blvd.,
21. City
22. County
23. State
24. Zip Code
Sebastian
Indian River
FL
32958
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
-711114
26. Signat re of Candidat
X
27. Treasurer's Acceptance of Appointment (fill in t e blanks and check the appropriate block)
1 Jerome Adams do hereby accept the appointment
(Please Print or Type Name)
designated above as: X❑ Campaign Treasurer Deputy Treasurer.
7/04 X
Date ig ature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C.
STATEMENT OF
CANDIDATE
(Section 106.023, F.S.)
(Please print or type)
1, Jerome Adams ,
candidate for the office of Councilmember ;
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
X
Signature of Candidate
71i h4
Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS -DE 84 (05/11)
ELIGIBILITY TO HOLD OFFICE
OF COUNCILMEMBER
Charter Section 2.02 - ELIGIBILITY
c;JU� ° ! aDl
Y Of k
ty
Cis o�c�
"No person shall be eligible to hold the office of council member
unless he or she is a qualified elector* in said city and actually
continually resided in said city for a period of one (1) year
immediately preceding the final date for qualification as a
candidate for said office."
I, J E11F01v E ADA10S , candidate for the office
of Council Member, meet the eligibility qualifications to hold office as
required in Section 2.02 of the City of Sebastian Charter, above.
L,17,ature of Can d-idate
Sworn to and subscribed before me this day of
2014
1G�
SALLY A MAIO X. 4 Notary P U IC = `1 - commission # EE 024350
ry- o, Expires October 5, 2014
State of Florida ` BMW T UT�Fen 705
SEAL
*166.032 Electors.- -Any person who is a resident of a municipality, who has qualified as an elector of this
state, and who registers in the manner prescribed by general law and ordinance of the municipality shall be a
qualified elector of the municipality.
Ms- word/election /charter eligibility
t