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
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(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.