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. 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)
S 04, tot.".c...Q / a . .4,,.5
3. Address (include post office box or street, city, state, zip
code) 2gOS ?4 Gad r 1,,,,,, /' l /- .'
Or A' -'ddb AC.3zFoS
4. Telephone
( Y67)S77-ash
5. E-mail address
SBrtiGS14td4caw,
6. Office sought (include district, circuit, group number)
0�-•-••-►efr;°E) "JR"" DIVYle •.C74 j
7. If a candidate for a non 'artisan office, check if
applicable:
0 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 ErCampaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
ref) 0-4 :.vs# ac 4 • . ..r
11. Mailing Address
6 S-Yy` ko y % r:✓ -,Q fi'r 4.cf -
12. Telephone
(ii07) ay.- 577/
13. City
Oita" i
14. County
0e-12.•ode.
15. State
FG
16. Zip Code
3,ae/0
17. E-mail address
TLaver•vA€ aolco c...,
18. I have designated the following bank as my ["Primary Depository 0 Secondary Depository
19. Name of Bank
AWee Oct euk
20. Address
7/...5- So Go ldw .v AlAto tV e
21.
r- lam
22.
D r"G N
23. State�
L
24. Zip Code
3c2d'OS
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR OINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FAC D IN IT ARE TRUE.
25. Date /
d -A ./...,
!«Treasurer's
26. Signature andidat
27. Acceptance of Appointment (fill in the blan and check the appropriate block)
I, \ t ry-S ‘--~ S. , do hereby accept the appointment
(Please P • or Type NJ e)
designated above as: Campaign Treasurer .i = r: r.
3/4/2 ()/s X r,; ,
Date W : gna re of C. paign Tre rer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.