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APPOINTMENT OF CAMPAIGN TREASURER CJ
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AND DESIGNATION OF CAMPAIGN C1tjC!,_ebastlz,
DEPOSITORY FOR CANDIDATES C'<
(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. OFFICE USE ONLY
,,1. ¢HECK APPROPRIATE BOX(ES):
Jr'x�f Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. NannA of Candidate (in this
soorder: Fir Middle, Last) 3. Address (include post office box or street, city, state, zip
DSV/4�code} �rI!0 6eral�ci S,-4
4. Telephone 5. E-mail address 3� `
(77A 9«0111��rri Sid ea <0/)6
6. sought (include strict, circuit, group number) 17. If a candidate for a nonpartisan office, check if
applicable:
�
S ,St taYl C " coo, nU ( � I ❑ idly intent is to run as a Write -In candidate.
8. If a candidate for aap Risan 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 parson to act as my Campaign Treasurer Ff Deputy Treasurer
10. Name of Treasurfr or Deputy Tre-&Qre
of P0,
11. Mailing Address / t 12- Telephone
516 6ela" S)_ �1_7a) c� f Tal I
13. City 114. County 15. State 16. Zip Code 17. E-mail address
�baS4iar f -t -r% rkA F( 13DqS`�Ipj wLa(arr�SS)(oSOKmg.c
18.1 have designated the following bank as, my Primary Depository ❑ Secondary DepositoryC A�
19. Nam o' f Bank 20. Address \S101 �j q
�'cc�Il bank I i ,1
21 �jt ` 122.E n Q �I Vw t 23. StatR r virf 17p"l 0z0
1 UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGNNy,,�POSITORY AND THAT THE FACTS STATED IN IT ARE TRUE
27. Treasurer's Accepta a of Appointment (fill in the blanks and check the appropriate block)
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1 + N'INL4(G1 V2 < do hereby accept the appointment
(Please/Print or Type Name)
designated above as: Campaign Treasurer Depu Treasurer
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (R=ev. 10110) Rule 1S-2.0001, F.A.C.