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 campalpn account.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
[] Initial Filing of Form Re -filing to Change: f Treasurer/Deputy [] Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
�.i�-r�,4 .k. C L4Av\ ,E,2 -s
3. Address (include post office box or street, city, state, zip
code) 1101 TtItCHI Lb C )1tr
O'(_L-A t4.Ta t K L S2-8.51"
4. Telephone
('h1 )1'1n- 9412.
5. E-mail address
INA4taar, vo@ rad.
6. Office sought (include district, circuit, group number)
C..t11 1 Gvr-4Ml S Stv►JE A- oT bit -AN -too
;7 t 5112 cT 4>
7.1f a candidate for a nonpartisan office, check if
applicab e:
My intent is to run as a Write -In candidate.
S. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a
Ei Write -In II No Party Affiliation [] Party candidate.
9. I have appointed the following person to act as my Campaign Treasurer 0 Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
ll
11. Mailing Addressi
<,-, )6-3 td / . // 1- 1 " ii2 Da- -
12. Telephone
(.)- I) 9qf 319 7
13. City,
1)0/4N d
14. County
04 10 1
15.1 State
FL-
16. Zip Code
Pau
17. E-mail address
/z -► .4-;-).,
18.1 have designated the following bank as my aEr Primary Depository ❑ Secondary Depository
19. Name of Bank
tSAAA K. DT- J�•MeRtcA I
2u. Aaaress
$3ti, 1 4,1.. 8.-ot.vri,tAt� vet46
21. City
v uo-o
22. County
o e..maGie
23. State
FL..
24. Zip Code
3 t8os
UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND TH THE FACTS STATED IN rT ARE TRUE.
25. Date
to 1 i 7 r
2 . ature of Candidate
x ---.► ! (---. '-
27. Treasu r' Accept c of Appointment (fill i e/blanks and check the propriate block)
I, (p % AS,do hereby accept the appointment
( eas n t or Type me)
designated above as: Campaign Treasurer C] Deputy Treasurer.
6- /7. / .s x i i2� 'L",
Date Signature of Campa gr treasure or Deputy T asurer
DS -DE 9 (Rev. 10/10)
Rule 13.2,0001, F.A.C.