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.
_ 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)
0-......., 4- / f . Div
3. Address (include post office box or street, city, state, zip
7,--elade 4.0...4.4444.4.0...4.4444.77--.04,„ /
code) z4,43.5,-
4. Telephone
ll��
( f' 7 )S72 -ered
5. E-mail address
stz-A ssie c ca.••..
Qr/a.ikacy �C. 3 2 O.S
�
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check If
65•- 0--; /j,.6 0J er- De i ,r t t.74 6
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 Erio Party Affiliation
•
Party candidate.
r
9. I have appointed the following person to act as my 0 Campaign Treasurer Er Deputy Treasurer
10. Name of Treasurer or Deputy Treasurerer-s
11. Mailing Address
Zeds re- a v4e w. 77G.: /
12. Telephone
(ed7 ) d'702 -4s-%3'
13. City
or%a...JA
14. County
di -43, 02
15. State
/G
16. Zip Code
JZPQ..t~
17. E-ma'I address
S47 -416r CaRcao/ CO 4.1,--..
18. I have designated the following bank as my p• --Primary Depository ❑ Secondary Depository
19. Name of Bank 1
4 )fi .. #''� 34%,%,) 4-
20. Address
714 fo c..7€ C04/4410v wy,v ,4€,' w e_
21. City
Qr t C
1 22. County
or -0, -.:ye
23. State
A -G
24. Zip Code
113.Z,f)DS"
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 STA IT ARE TRUE.
25. Date
S/6/g CV -r-
26. Signature of ate 1
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I, �Q 1.1-"i CA. e_/ 4• or .,f , do hereby accept the appointment
(Please
designated above as:
/ ZG /.S-
Print or pt- Name)
■ Campaign Treasurer Er--- u easurer
X
Date Signature Campaign Treasurer or Deputy Treasurer .. ------_
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.