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):
Initial Filing of Form Re -filing to Change: Treasurer/Deputy ❑ Depository ❑ Office Party
2. Name of
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Candidate (in this order: First, Middle, Last)
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3. Address (include post office box or street, city, state, zip
code) ila W4V+tn L . v_tit j Oh
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4. Telephone
( Lirn )1 I i-71-11SD
5. E-mail address
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6. Office sought (include district, circuit, group number)
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7. If a candidate for a non • artisan office, check if
applicable:
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My intent is to run as a Write -In candidate.
8. If a ca✓✓ndidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a
❑ Write -In D No Party Affiliation Party candidate.
9. I have appointed the following person to act as my [] Campaign Treasurer d Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
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11. Mailing Address
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12. Telephone
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13. City
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14. County
01'3-a.ile_
15. State
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16. Zip Code
3LV
17. E-mail address
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18. I have designated the following bank as my g Primary Depository ❑ Secondary Depository
19. Name of Bank c
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20. Address
21X0 s. U-1-a,tt.y Ave_
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21. City
00 ai _cl 6
22. County
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23. State
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24. Zip Code
3n01
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
2-017
26. Signature of Candidate
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27. Treasurer's Acceptance of Appointment
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(fill in the blanks and check the appropriate block)
2 , do hereby accept the appointment
designated above as:
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(Please Print or Type
0 Campaign
S , a
Name)
Treasurer Deputy Treasurer.
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Date Signature of Campaign Tr asurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.