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.
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OFFICE USE ONLY
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1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: [] Treasurer/Deputy ❑ Depository ❑ Office
IN
Party
2. ie f Candi ate (in this order: r -t, Middle, Last)
k7/61- ,�'
3. Address (include post office box or street, cl
code) . P/S- Clinr�4� i
o / _! k3�1�Z
y, state zip
K P`3/ 7
4. phone
5. E-mail address
6. Office s ught (include district, circuit, group
!inr17/ SS/U P.- /—
C.-647 ii, a awa'
nu er)
/ S z�
7. If a candidate for a nonpartisan office, check if
applicable:
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. I have appointed the following person to act as my [l Campaign Treasurer ❑ Deputy Treasurer
10. Name of r asurer or Deputy Treasurer
3h rv- Y1 Bea. 1
11. Mailing Address
282tD 5l ILWO(d 0,.1-i/ 114
12. Telephone
(?(3) GOvJ tSlOZ
13. City
Orl [)
14. County
torox,GiP
15. State
FL
16. Zip Code
3 2 818
17. E-mail address
S Irearrtrnvnh cDTrai I-cokN'
18. I have designated the following bank as my 12I Primary Depository ❑ Secondary Depository
19. Name of Bank i /► A
20. Address
21. City
Er0 /9C0
22. County
e2f6r✓y�
23. State ./(
24.Zip ��
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UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE,
25. Date
a-10•is--
26. Signature of C to
x
27. Treasurer's Acceptance ofAppointment (fill in the blanks and check the ropriate block)
I, S Vla r t \ t r- CX.. l , do hereby accept the appointment
(Please Print or Type Name)
designated above as: `, Campaign Treasurer
10'11S-- X tur ( e
0 Deputy Treasurer.
Date Signature of lampaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.