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.
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1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order:
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First, Middle, Last)
3. Address (include post office box or street, city, state, zip
code) `360 AR...16A 9r
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4. Telephone
(4-61 )03.03-1
5. E-mail address
ristuAri-g4,14,04mAil.core
CALA it- 3.24 01
6. Office sought (include district, circuit, group num r)
0MIA Na CVO/ CpVn/G1L, I))5 .
7. If a candidate for a nonpartisan office, check if
applicable:
My3 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 ❑ Campaign Treasurer
►.M Deputy Treasurer
10. Nameof Treasurer or Deputy Treasurer
11. Mailing Address
r 6o Arni„rt. S i
12. Telephone
(+Ai-) ) 473
0 C37
13. City
612A-ANDo
14. County
O(LANI
15. State
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16. Zip Code
32-8(3 4-
17. E-mail address
rf Apt Sb7 cs IAA; 1. tool
18. I have designated the following bank as my Primary Depository ❑ Secondary`Depository
19. Name of Bank
I'WA 15RtK-
20. Address
1ct01
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21. City
22. County
23. State
24. Zip Code
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
3 1 1-2-o17
26. Signature of Candidate
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27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I 1ZOT362T t' 9-nVA( , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer a Deputy Treasurer.
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t Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
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