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.
ORLCITY0 ER
NOV218 Pm3:
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
EJ Initial Filing of Form Re -filing to Change: Treasurer/Deputy ❑ Depository Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
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3. Address (include post office box or street, city, state, zip
code) (D.13a\, (p 7'j 53`-1
Or\ at\ 0) FL 3M -6 r/
4. Telephone
( 1 )'&30-(4(0)(0
5. E-mail address
.1.eA nne,At jAo\.Com
6. Office sought (include district, circuit, group number)
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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 andfillin name of party as applicable: My intent is to run as a
Write -In ❑ No Party Affiliation [V� De.m 0Cea`1-1'C, Party candidate.
9. I have appointed the following person to act as my ❑ Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
I /A 1-
11. Mailing Address
°)Ct. p
12. Telephone
( ) Savy) -02._
13. City
._Ctw1 e_
14. County
S air, e.
15. State
Soon e-
16. Zip Code
5 a.vv, e_
17. E-mail address
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18. I have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank
anK 0- NmP�icc�
20. Address b(cint..,iP' Avg
21. City
Dram C1,0
22. County
brace c)e._
23. State
T 1._
24. Zip Code
3a�S0I.
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
OC. �J :i,a(Dl�
26. Signature of Candidate
X -�.on-v,I I �
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I, J \ , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
/6 /3/ /b X
Date Signature of ampaign Treasurer or Deputy Treasurer
Rule 1S-2.0001, F.A.C.
DS -DE 9 (Rev. 10/10)