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 t
officer before opening the campaign account.
OM_ I^`
a, ,�r.q
OFFICE US `dN"LY
1. CHECK APPROPRIATE BOX(ES):
k'.1 Initial Filing of Form Re -filing to Change:
Treasurer/Deputy
Depository ® Office Party
2. Name of Candidate (in this order: First, Middle, Last)
'jZog code)
�.tiT 1`.. ���Aa.ti
3. Address (include post office box or street, city, state, zip
1300 Akf%v& g -Si -r-
4. Telephone
(*-01) 4-4-$400i7
5. E-mail address 0 LAND() 'CL '2j2$(
riStv0,474A ® mai1.Cow)
6. Office sought (include district, circuit, group numb)
�p //�
t .Lo Gr� I�OVNCi.. i )))'9V. 3
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 ❑ 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�
JAcAR V. 57vv"-- Vz-
11. Mailing Address
.37 N o w /tV6, Pr 1100
12. Telephone
(+07 ¢i4 033 c f
13. City
0 H•AAAC,
14. County
oflifqX
15. State
F`
16. Zip Code
3 247d1
17. E-mail address
f.ub e rA;s t.. ro
'cot.
18. I have designated the following bank as my 14. Primary Depository ❑ Secondary Depository
19. Name of Bank
1 bfn- A •ANK.
20. Address
1 q4 i fi( 'wq it.. Do..
21. City
°ELAtto
22. County
0201/444
23. State
fl-
24. Zip Code
3?47o¢ A
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
4A 'O t ,u 17
26. Signatureltu of Candidateat
X T �'/'
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I, /41G0150 V Teal'/I-- , do hereby accept the appointment
(Please
designated above as:
Print or Type Name)
LI Campaign Treasurer Deputy Treasurer.
Stir/
Date _•. a e of •:mpai nn Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.