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: 1111 Treasurer/Deputy ❑ Depository [] Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
J�sa� v�r, �Ivrn e.
3. Address (include post office box or street, city, state, zip
code) q f( m A ii --60 & J.
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O(L/'4" 690, 3237
4. Telephone
(l/ ' )-j(P3- / 3
5. E-mail address
JAS,»v�,,,,40rne,�i'vle. c
6. Office sought ((include district, circuit, group number)
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0✓ 1p n�o C 4 Covo c.._:' J
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7. If a candidate for a nonpartisan office, check if
applicable:
My intent is to run as a Write -In candidate.
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8. If 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
111
Party candidate.
9. I have appointed the following person to act as my Campaign Treasurer Deputy Treasurer
10.1 Name of Treasurer or Deputy Treasurer
)/=) S On fJA h OY f') e--
11. Mailing
1///1
Address
Thal -T -9-O I ,
,1(2. Telephone
N0-7 )h (f 43 - /73R-
13. City
14. County
15. tate
16. Zip Code
17. E-mail address
18. I have designated the following bank'as my Primary Depository Secondary Depository
19. Name of Bank
4'361 i 5 Ps v -S o /J i4
20. Address
Ce / 0 5`_ OrA/i A �c
21. City
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or .rm cP v
22. County
0,'ia n -cam
23. ate
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24. Zip Code
,:3 -d
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND T FACTS STATED IN IT ARE TRUE.
25. Date
1
0
i
. Signature of • . .idate
r —y
27. Treasurer's Acceptance of Appointment (fil in e blanks and check the appropriate block)
JA S 0 r--, („)pi 1-> %4Uf'h L , do hereby accept the appointment
(Please Print or Type Name)
designate above as: Campaign Treasur Deputy Treasurer,
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Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.