HomeMy Public PortalAboutAppointment of Campaign Treasurer (4)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): L 6 `'' 7
❑ Initial Filing of Form Re -filing to Change: a TreasurerlDeputy ❑ Depository 0 Office ❑ party
2. NameofCandidate (in this order: First, Middle, Last)
'.JA ` "% il h1 4, c i f A M r3 L -4S
3. Address (include post office box or street, city, state, zip
code) cl) D`i P.OTH C (-I i e.� c't ,
Dq r --G r) p 1 p L 32-V35
4, Telephone
(447-1 ) )_g4Jz
5. E-mail address
ha llai UT b e . 0.1 , I Pca0/1
6. Office sought (include district, circuit, group number)
C 1 TY 0 C ►-f MISS) o N Ell j) 13fia 1 c:r4_. U Qi bJi) a
7.0 a candidate for a nonparjisan office, check If
applicable:
myintent is to run as a Write -1n 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 ❑ Campaign Treasurer ® Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
A D M I ti...) t Q A e -d t► i- 0.1-1--,40-ASeies
11. Mailing Address
(1 10 9 P -u i i -I C (- l t_: C_1
12. Telephone
(4P-7) Ss6,q-.-.,C if
13. City
b e -C A0 7 o
14. County
Oy2-A i 6E
15, State
t L
16. Zip Code
32---12;i
17. E-mail address
rns pac ,t, 1 o C aj,nela,t Co.,1
18.1 have designated the following bank as my VI Primary Depository 0 Secondary Depository
19. Name of Bank 120.
e)A F-� k b VII ,4-4&a---(e—Li,
Aadress
I 5 &I l� �Y.J r L 0 1� 1 M L "ba l v E
ll
21. City 1? L I
" U
22. County
0(2—A G l
23. State
24. Zip Code
32g56
UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT E FACTS STATED IN IT ARE TRUE.
25. Date
r-� ! - ) S
sign re of Candidate
X )tk - -s
27. Treasurer's Acceptance of Appointment (fill in t e tanks and check the appropriate block)
1, ePtib f'>,1 r.1 ( l'----) r A 1 II - C- [ 4 A 1 SE -e-5 , do hereby accept the appointment
(Please Print or Type Name)
designated above as: ❑ Campaign Treasurer
a Deputy Treasurer.
.
171)61 ) i 5 X , ----
at Signature of Campaign Treesdler or Deputy Treasurer
gp Y
DS -DE 9 (Rev. 10/10)
Rule 18-2.0001, F.A.C.