HomeMy Public PortalAboutCampaign Treasurer's ReportAPPOINTMENT 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. Na a of Candidate (in this order' irst, Middle, Last)
i7-0 it v 4_ 4-77Z
3. Address (include post office box or street, city, state, zip
code)
Al4 ephone
5. E-mail address
6. Office sought (include district, circuit, group number)
e0"WA-,;L,SL.i c,‘,16( i r 47 2-
7. If a candidate for a nonpartisan office, check if
applicable:
11111
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
111
No Party Affiliation ❑ Party candidate.
9. I have appointed the following person to act as my gr Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or�De uty T asurer
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11. Mailing Address
12. Telephone
(16-7- ) 8?6, - 254,P(
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Z/ c /16- ��.
13. 91,y,
4 4t/25t
1.4,,County
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15 Late
16. Zip Code
J- 3
17. E-mail address
18. I have designated the following bank as my ITI Primary Depository
III Secondary Depository
19. a of �B�a� •,
i}7�i�a/(!' 2u C?".D';' % 1.41/Ail
20. Address /' ti
13 I517 J
21. Cit
4 64 AtD o
22. Cou y
d/ S`.
23. Stat
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24. Zip Code
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UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TR
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
SURER AND
25. Date
26. Si
Ca didat
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate b
I, •-••--ilae�Ar - (9/94- y accept the
)
ppointment
(Please Print or Type Name)
designated above as: g Campaign Treasurer
l2- 2iS X 40
Deputy Treasurer.
v
Date Sign ture of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.