HomeMy Public PortalAboutAppointment of Campaign TreasurerAPPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(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
1.9i4ECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Mid. -, Last
JcAvi �gir Aild� ~r y
irp
3. Address
code) 10%3
(include post office box or street, city, state, zip
Thr h tlawr 54
orl&vicio l, 1E604
4. Telephone •
(4Q ) 3'IV CRP
5. E-mail address
tea acv 11. toot
6. Office sought (include district, circuit, group number)
Aa5ve ( OA 8dL
7. If a candidate for a nonpartisan office, check if
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 0 No Party Affiliation ❑ Party candidate.
9. I have appointed the following person to act as my 2rCampaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
CA/VD/EA" S C€Aa)Fo,eo
11. Mailing Addres •
1.2•27 PtIve # 1e eel/e Creed-
12. Telephone
(#O1) y`1-1as
13 City
AHA#ii+c$r1R,j
14. County
Se m
15. State
Fl
16. Zip Code
J 7/ y
17. E -ma I address
U M) Fo R D' ®.+Wwn .Cep
18. I have designated the following bank as my
F:4
Primary Depository ❑ Secondary Depository
19. Name of Bank
Sew s ick itholoiwif Asat v-30.11/61.
20. Address
loo «). "Yltotrse'thi1 Oi/oD
21. City
In4er-**NW-
22. County
D NSA
23. State
P1
24. Zip Code
3ZVB9
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 Can. •a e
27. Treasurer's Acceptance of Appointment (fill in the blanks and checItt appropr a block)
I, e Ammo Cpl AIOrole c• , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer
1- o 1' /s X
III Deputy Treasurer.
•
. e c
Date Signature of Campai Treasurer or D Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.