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HomeMy WebLinkAboutAdams DSDE9 Change of DepositoryAPPOINTMENT OF CAMPAIGN TREASURER RECEIV�p AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES JUL (Section 106.021 (1), F.S.) 2014 Crt of y o (PLEASE PRINT OR TYPE) Caty C!e ses she NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): El 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 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-1 2@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 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@a att.net 18. 1 have designated the following bank as my Q Primary Depository Secondary Depository 19. Name of Bank 20. Address Wells Fargo 1524 US HWY 1 21. City 22. County 23. State 24. Zip Code Sebastian Indian River F 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 26. Signature of Candidate 7/912014 X. 27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block) 1 Jerome Adams do hereby accept the appointment (Please Print or Type Name) designated above as: 0 Campaign Treasurer Deputy Treasurer. r 7/912014 x _ A�,,vo Date Signature of Campaign Treasurer or Deputy Treasurer DS -DE 9 (Rev. 10110) Rule 1S- 2.0001, F.A.C.