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.
DRL CITY CLERK
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H, RIB 1_ I* HMf_1•, 4,
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
A Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
/�% �. �
3. Address (include post office box or street, city, state, zip
code) /
9 778' e/.9-NDFi� Q D AD .
D,Qli '• �"/. p
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4. Telephone
(1407 ) 77o -,70
5. E- ail address
gm. GRahi
6MyPa1 GtPr .. Cam
6. Office sought (include district, circuit, group number)
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D�iTLL��ioe L/' 6m.4/4/ �,S?�'/Cr
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 *artisan 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 X Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
*Gl554 ./P/..r
11. Mailing Address
8 5:3, Zovfif dv •
12. Telephone
(,Y50) a% - y'22
13. City
elG oo
14. County
466iNGZ
15. State
P<
16. Zip Code
3Z83
17. E-ma'I address
/j1gwo16 /9- y lD:•:; ref-. c
18. I have designated the following bank as my A Primary Depository ❑ Secondary Depository
19. Name' of Bank
Oat s X 60
20. Addressre
/€ ` ! l'Cr , ?c o-s:5F(' / L=..
21. City
,44,7--/t/d%
22. County
�.�9N6` e
23. State
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24. Zip Code
..�.. � ? 2.
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
1/4 /472°( 7
26. Signature Candi ate
X _-
27. Treasurer's Acceptance of Appointment (fill in the bI4 ks and check the appr riate block)
I, / .%/5S, Cif }- , do hereby accept the appointment
(Please Print or Type Nar
designated above as: iNs Campaign Treasurer ❑ Deputy T asurer.
/0/2.- ‘./ .Poi 7 X
Date Signatu of mpaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10110)
Rule 1S-2.0001, F.A.C.