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 campaign account.
FEB 1 201g 4110: 2:3
OFFICE USE ONLY
LIC71 K APPROPRIATE BOX(ES):
nitial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last
..dnr1, ktugh oar a. N V.I p1 ,LO C r
3. Address (include post office box or street, city, state, zip
code)
p,o.? 22o
c4.Telephone 2
5�\a"3:A\9L ^@
Oy \O o , (�- -'321%(:)2_
district, circuit, number)
7. If a candidate for a nonpartisan office, check if
6. Office sought (include group
vn C - c, ^ Y
M a,-)QY ,% cC o
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 ❑ Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
-1ciD C\ -Te nni
11. Mailing Address
‘ OLP 'E . tAOtY JOX d .-t .
12. Telephone
(`ACA )Q2:1- --60°I°i
13. City
CV antic)
14. County
OrarQe.
15. State
�l...
16. Zip Code
3Z -1
17. E-ma.l address
-,N5j2Q-tCD @ U.ok .Corr)
18. I have designated the following bank as my IVPrimary Depository 0 Secondary Depository
19. Name of Bank
acoa Wane.
20. Address
\03\ v. vtovse \\./cA . -\s0
21. City
v.lfl eY 00,0 4-
22. County
C>r OlYlg
23. State
FL-
24. Zip Code
`2.1--%0\
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
2.1. 1Ct
26. Signature of Can
X
. to
27. Treasurer's Acceptance of Appointment (fill in the blanks nd ch k the appropriate block)
J 11 / 'i I rl l i- i q 6 , do hereby accept the appointment
(Please Print dr Type Name)
designated above as: ❑ Campaign Treasurer
2_ - / - / Li X
i
Deputy Treasurer.
C lc.->t--r---7c /
Date ignature of Campaign Treasurer or Deputy Treasurer
ma.. i e n nnn4 C A !`
DS -DE 9 (Rev. 10/10)