HomeMy WebLinkAboutDSDE9RECfi�VED
APPOINTMENTAND DESIGNATION OF AMPAIGNRER C1ty O
DEPOSITOtioRY
1106 ORICANDIDATES CS CosebO�ice
(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):
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
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/`�
code) y38�(yE° /3Au 1. a' r/
4. Telephone 5. E --mail address Po 3-A 7 3� c
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y7// 7
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
applicable:
❑ My intent is to run as a Write-in candidate.
S. If a &ndidate fora partisan office, check block and fill in name of party as applicable: My intent is to run as a
❑ Write -In ❑ No Party Affiliation [j
Party candidate.
9. 1 have appointed the following person to act as my 2rcampaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
j?WrIetc-.46 00'
11. Mailing Address 12. Telephone
13. City 14. County / 15_ State 1 16. Zip Code 17. E-mail address
So/3/�STi��/ Ie%/,M.�/l,/.t✓ ��' 3197Y ees'.a.y/j,�`.16f1C����l C��
18. 1 have designated the following bank as my Primary Depository ❑ Secondary Depository
19. Name of Bank 20. Address
OCvlihlr} /.:;OA/-,/ /j4eo 4S /J,f4•J,aj/ -t-
21.
21. City 22. County 1 23. State 24. Zip Code
1r/JerTsA/ 2,✓11WW � Jrn— r� i1 f rte
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 F CTS STATED IN IT ARE TRUE.
25. Date 26.S1 u f Can d e
27. Treasurer's Acceptance of Appointment fill i t e an s d check the appropriate block)
?'f��/ do hereby accept the appointment
(Please Print or Type Name)
designated above as: Er� Campaign Treasurer /� Deputy Treasurer
Date r Signature oTpC�aTiipaign Tree r o e Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.