HomeMy Public PortalAboutAppointment of Campaign Treasurer (5)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 ONL
1. CHECK APPROPRIATE BOX(ES):
❑ Initial Filing of Form Re -filing to Change: 'j2, Treasurer/Deputy ❑ Depository 0 Office ❑ party
2. Name of Candidate (in this order: First, Middle, Last)
NAT\-AI�. A, L` t�q�(3sa5
3. Address (include post office box or street, city, state, zip
code)
D Q.C..-A1-tbO t 1 3z B 3c)
iv,
4, Telephone 15.
(4-1) fi ri o -c(4-1 Z
E-mail address
rt a-tAn ck yorl i to J oJrnc6 k.o
6. Office sought (include district, circuit, group number)
.. 171 C n hM 1551 D 1J ea l7\S1r.IL.'_ 6 _ b a-4130-'s)" applicable:
7. If a candidate for a nonpartisan office, check if
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 JJ Campaign Treasurer 0 Deputy Treasurer
10. Name oar surer or
,y�)c
urer
Deputy T77io
I
11. 44 iling Address
/vr Q�N
ll �) /� P4'kfw
DV t�
12. Telephonne[�/f�% �yb/c3
(�0/) U'7 1—/$11.�
13. C'ty
1 Ef
14. ount Y
[J
15. State
r
16. Zip Code ,
17. E-mail address
C. ke_ r l tI v ina 5 i l e qv], Low?
18. I have designated the following bank as my jzi Primary Depository ❑ Secondary Depository
19. Name of Bank i 2U. Aadrass
ZA0k Di- At-keeieA I 53 B) 14.• COLDt--l1ftC •DaiyE,
21. City
012 1J1)0
22. County
O0-.-Ao (21 r_
23. State
"•L
24. Zip Code
3aB3 5
UNDER PENALTIES OF PERJURY, 1 DECLARE THAT 1 HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMP/USN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT E FACTS STATED IN IT ARE TRUE.
25. Date
7/f/K
2 re of Candidate
X 44, . ____, t „ ,.-,—. i
27. Treasurer's Acceptance of Appointment
I, rilex J 7' off , .
(fill in the larks and check the appropriate block)
r , do hereby accept the appointment
(Please Print or Type Name)
designated above as: 0 Campaign Treasurer Deputy Treasurer.
q_ 9r-1,5- X )
Date natu algn Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 13.2.0001, F.A.C.