HomeMy Public PortalAboutAppointment of Campaign Treasurer (2)APPOINTMENT 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.
i ,.. A, ��-�a vP
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
El Initial Filing of Form Re -filing to Change Treasurer/Deputy ID Depository
• Office r] Party
2. Name of Candidate (in this order: First, Middle, Last)
3hn `.vcfiL Dtier,�R {� �1 my D�(er
3. Address (include office box or street, city, state, zip
post
code) Px,/�//wi�- ,?� 9
�,4.0 uute, 4 52 -cot
4. Telephone
(Ye )9'6,7-'7g52
5. E-mail address
0 . J i_d iu n -corn-,
6. Office sought (include district, circui , group number)
Lace-' Z Od 0
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
E Write -In p No Party Affiliation
•'
Party candidate.
9. I have appointed the following person to act as my la Campaign Treasurer
1111 Deputy Treasurer
10. Name of Treasurer
C riA/0I
or Deputy Treasurer
tL) C , » 0
11. Mailing Address
1,a7f.' �£-04
12. Telephone
( )
13 City
jf_
14. ounty
15. State
16. Zip Code
17. E-mail address
18. I have designated the following bank as my ,' ? Primary Depository
■ Secondary Depository
19.
,
pJame of Bank /� 1�
J2 LadeCep % l( eLln‘604-4_,)- 4
20. Address D
1100 I . L%ihew /� 'War j ` X00
2 ity ,
1.i P01 -4-k
22. County
0h°1 -'`5.e._
23. State
N. 11
24. Zip Code
3d in
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
\51 ` /51
26. Signature�of Candidate
X I ` 4
27. Treasurer's Acceptance of Appointment (fill in the blanks and . k the app priate block)
1, AN,O / Cr `S • e-2 4 W FO (. 6 , do hereby accept the appointment
(Please Print or Type Name)
designated above as: a Campaign Treasurer 0 Deputy Treasurer.
- / X ( -4 i
Date Signature of Cam aign Treasur Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.