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
1. CHECK APPROPRIATE BOX(ES):
L1 Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate
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(in this order:
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First, Middle, Last)
3. Address (include post office box or street, city, state, zip
code) 350( --fors 5 Dr-iNe____
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4. Telephone
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5. E-mail address
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6. Office sought (include district, circuit, group nurPt er)
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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 0 No Party Affiliation ❑ Party candidate.
9. I have appointed the following person to act as my ❑ Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer
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or Deputy Treasurer
R- S e p' -1 es
11. Mailing Addres
2452- VIedmon- S--
12. Telephone
(40-7)(/).26:- -`/‘1--
13. City
14. County
15. State
16. Zip Code
17. E-mail address
18. I have designated the following bank as my ❑ Primary Depository ❑ Secondary Depository
19. Nam of Bank
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20. Address A1)(1
//5-Sa v70(f wY1 ACtI,
21. City
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22. ounty
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23. State
FL_
24. Zip Code
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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
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V\ 02/11 D(
26. Signature of Candidate
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27.
I,
Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
, , 6041 K' _Sc. AAA -5 , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
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Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
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