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: his form must be on file with the qualifying
office efore opening the campaign account.
OFFICE USE ONLY
1. HECK APPROPRIATE BOX(ES):
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) / (e LUT di9-4 ,ST
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4.Telephone
( `-10-7) 839..3&I5
5. E-mail address q) go ,
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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:
intent is to run as a Write -In candidate.
8. If a candidate for a a ' an 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 ampaign Treasurer 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
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15. State
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16. Zip Code
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17. E-mail address C) 9UL
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18. I have designated the following bank as my Primary Depository E Secondary Depository
19. Name of Bank
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20. Address
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21. City
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22. County
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23. State
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24. Zip Code
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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
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26. Signature of Candidate
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27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I, A A Poi A c i , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
Ob — 03 - .7.-0-/ 6 __________
Date Signature of Campaig- re. . er or Depu asurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.