HomeMy Public PortalAboutWHITE - Filing DocsAPPOINTMENT 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.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re- filing to Change: ❑ Treasurer /Deputy ❑ Depository Office Party
Name of Candidate (in this order: First, Middle, Last)
3. Address (include post office box or street, city, state, zip
`2.
JdNN 5PAGNA VvH «
code)
also AVENUE AV
Gt)I -F 51-RE M F L 33'-I -B 3
4. Telephone
5. E -mail address
( 561 )a'1q -�4q
4wh'l -e 5c�l�- ��rrt:arri.or
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
TOWN CfMNSIoNER //OL V
SEA
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. 1 have appointed the following person to act as my LS Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
b0NtJfl SPAGN* WA ITE
11. Mailing Address
12. Telephone
d,950 AVENUE � AO SO L EI L
( )AW _ 1+04q-
13. City
14. County
15. State
16. Zip Code
17. E -mail address
GULF EAM
PkLM
PL
33
a�sv ,i +� : g''� -�...h e m. g
18. I have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank
20. Address
e>RN-Y, or- AµQP ICA
4T LA N-n3 hvEmuE - WEST'
21. City
22. County
23. State
24. Zip Code
DELRWY BERC�4
1PALM NCH
F L
35 Lfg,5
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
26. S' ature of Candidate
27. Treasurer's Acceptance of Appointment (fill in the blanks and c ck the appropriate block)
\
I, p to N 4 S. W k 7[ , do hereby accept the appointment
(Please Print or Type Name)
designated above as: � Campaign Treasurer ❑ Deputy Treas er.
Z X 292�___
ate I Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C.
FORM 1 STATEMENT OF 2013
Please print or type your name, mailing FINANCIAL INTERESTS
address, agency name, and position below: FOR OFFICE USE ONLY:
LAST NAME -- FIRST NAME -- MIDDLE NAME:
F
1
MAILING ADDRESS:
RQ Souc
CITY : ZIP: COUNTY:
GUL-P S 3 PAL-K $lEnC
NAME OF AGENCY:
? 1RIE
NAME OF OFFICE OR POSITION HELD OR SOUGHT:
TONINL SS o R
You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF ';4 CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE
* * ** BOTH PARTS OF THIS SECTION MUST BE COMPLETED * * **
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR, WHETHER BASED ON A CALENDAR
YEAR OR ON A FISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING
EITHER (must check one):
DECEMBER 31, 2013 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THATAREABSOLUTE DOLLAR VALUES, WHICH REQUIRES FEWER
CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (see instructions
for further details). CHECK THE ONE YOU ARE USING:
COMPARATIVE (PERCENTAGE) THRESHOLDS OR ❑ DOLLAR VALUE THRESHOLDS
PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person - See instructions]
(If you have nothing to report, write "none" or 'Wa ")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
t rE W' - -:l# 4
i iAt_ l ST
L- -33 3,-2-
1
L FL
SION
hoFm or-
SOCIAL S�CUh?1T`i
PART B -- SECONDARY SOURCES OF INCOME
[Major customers, clients, and other sources of income to businesses owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or 'Wa ")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
A
PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or'Wa ")
FILING INSTRUCTIONS for when
and where to file this form are
located at the bottom of page 2.
NIB
INSTRUCTIONS on who must file
this form and how to fill it out
begin on page 3.
CE FORM 1 - Effective: January 1, 2014. (Continued on reverse side) PAGE 1
Adopted by reference in Rule 34- 8.202(1), F.A.C.
PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions]
(If you have nothing to report, write "none" or "n/a")
TYPE OF INTANGIBLE
PART E — LIABILITIES [Major debts - See instructions]
(If you have nothing to report, write "none" or "n /a ")
NAME OF CRED
BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
ADDRESS OF CREDITOR
PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions]
(If you have nothing to report, write "none" or "n /a ")
BUSINESS ENTITY # 1
ADDRESS OF BUSINESS ENTIT`
PRINCIPAL BUSINESS ACTIVITY
POSITION HELD WITH ENTITY
I OWN MORE THAN A 5% INTER
BUSINESS ENTITY # 2
IF ANY OF PARTS A THROUGH FARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑
Z,
ZL_sv
DATE SIGNED (required)
1q 11;;20/
If a certified public accountant licensed under Chapter 473, or attorney in good standing with the Florida Bar prepared this form for you,
he or she must complete the following statement:
I, , prepared the CE Form 1 in accordance with Section 112.3145, Florida
Statutes, and the instructions to the form. Upon my reasonable knowledge and belief, the disclosure herein is true and correct.
Signature
WHAT TO FILE:
After completing all parts of this form, including
signing and dating it, send back only the first
sheet (pages 1 and 2) for filing.
If you have nothing to report in a particular
section, you must write "none" or 'Wa" in that
section(s).
NOTE:
MULTIPLE FILING UNNECESSARY:
Generally, a person who has filed Form 1 for a
calendar or fiscal year is not required to file a
second Form 1 for the same year. However, a
candidate who previously filed Form 1 because
of another public position must at least file a copy
of his or her original Form 1 when qualifying.
FILING INSTRUCTIONS:
WHERE TO FILE:
If you were mailed the form by the Commission
on Ethics or a County Supervisor of Elections for
your annual disclosure filing, return the form to
that location.
Local officers /employees file with the
Supervisor of Elections of the county in which they
permanently reside. (If you do not permanently
reside in Florida, file with the Supervisor of the
county where your agency has its headquarters.)
State officers or specified state employees
file with the Commission on Ethics, P.O. Drawer
15709, Tallahassee, FL 32317 -5709; physical
address: 325 John Knox Road, Building E, Suite
200, Tallahassee, FL 32303.
Candidates file this form together with their
qualifying papers.
To determine what category your position falls
under, see the "Who Must File" Instructions on
page 3.
Facsimiles will not be accepted.
Date
WHEN TO FILE:
Initially, each local officer /employee, state officer,
and specified state employee must file within
30 days of the date of his or her appointment
or of the beginning of employment. Appointees
who must be confirmed by the Senate must file
prior to confirmation, even if that is less than
30 days from the date of their appointment.
Candidates for publicly - elected local office must
file at the same time they file their qualifying
papers.
Thereafter, local officers /employees, state
officers, and specified state employees are
required to file by July 1st following each calendar
year in which they hold their positions.
Finally, at the end of office or employment, each
local officer /employee, state officer, and specified
state employee is required to file a final disclosure
form (Form 1 F) within 60 days of leaving office or
employment. However, filing a CE Form 1 F (Final
Statement of Financial Interests) does not relieve
the filer of filing a CE Form 1 if he or she was in
their position on December 31, 2013.
CE FORM 1 - Effective: January 1, 2014. PAGE 2
Adopted by reference in Rule 34- 8.202(1), F.A.C.
STATEMENT OF
CANDIDATE
(Section 106.023, F.S.)
(Please print or type)
1, -3�0 W N.A 5PAGND W-H ITt
candidate for the office of AWN L°pW I's S 10WE1�, Glib r- S--RUi�H
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
x ,
Signatur of Candidate
"?/,q/ / Ll
Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS -DE 84 (05111)
CANDIDATE OATH -
NONPARTISAN OFFICE
(Not for use by Judicial or
School Board Candidates)
OFFICE USE ONLY
OATH OF CANDIDATE
(Section 99.021, Florida Statutes)
W �A ITE
(PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT' - NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING)
am a candidate for the nonpartisan office of TbW N COMM 15510NER. GULF SiREAVj
(office) I (district #)
I am a qualified elector of PA L M t= ERQA County, Florida;
(circuit #) (group or seat #)
I am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or
elected; I have qualified for no other public office in the state, the term of which office or any part thereof runs
concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to
Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the
State of Florida.
Signature of Candidate Telephone Number Email Addresy
aaM MENUE AU 5OLEIL C'-,<ULP s-TRE7R M F L_ 5516'3
Address City State ZIP Code
Candidate's Florida Voter Registration Number (located on your voter information card): I I a -9,FcR 4I
* Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons
with disabilities (see instructions on page 2 of this form):
�)AH - NA S. wEI
STATE OF FLORIDA
COUNTY OF P--Al q5 - ?,e L;
Sworn to (or affirmed) and subscribed before me this day of �� �/ ^ , 20
Personally Known: or a�
Signature of Notary Public
Produced Identification: Print, Type, or Stamp Commissioned Name of Notary Public
Type of Identification Produced: °sP '•& RITAL TAYLOR
* MY COMMISSION # DO 949851
s
"040"" Bonded Thru Budget N $e T
DS -DE 25 (Rev. 5111) Rule IV- X1.0001, F.A.C.
INSTRUCTIONS: INSERTING PHONETIC SPELLING OF CANDIDATE'S NAME FOR AUDIO
BALLOT
Use the PRONUNCIATION KEY below to provide pronunciations for ambiguous first names and surnames.
Capitalize STRESSED syllables, use lower case for unstressed syllables. Use dashes ( -) to separate syllables.
You should also add any notes such as rhyming examples, silent letters, etc.
PRONUNCIATION KEY
Stressed Vowel Sounds
EE
(FEET) feet
I
(FIT) fA
E
(BED) bed
A
(KAT) cat (KAD) cad
AH
(FAH -thur) father
(PAHR) par
AH
(HAHT) hot (TAH-
dee) todd
UH
(FUHJ) fudge
(FLUHD) flood
UH
(CHUHRCH) church
AW
(FAWN) fawn
U
(FUL) full
00
(FOOD) food
OU
(FOUND) found
O
FO foe
El
FEIT fight
AI
(FAIT) fate
OI
(FOIL) foil
Y00
(FYOOR- ee -uhs)
furious
Unstressed Vowel Sounds
uh (SO -fuh) sofa (FING-
uhr' rin er
Certain Vowel Sounds with R
AHR
(PAHR) par
ER
(PER) pair
IR
(PIR) peer
OR
(POR) pour
OOR
(POOR) poor
UHR
I (PUHR) purr
Samples:
NAME ON BALLOT
PRONOUNCED AS
Mishaud
mee -SHO ('d' is silent)
Jahn
HAHN (rhyme: fawn)
Beauprez
boo -PRAT (rhyme: hooray)
Maniscalco
man- uh- SKAL -ko
Tangipahoa
TAN- ji- pah -HO -uh
Monte
Mahn -TAI
Tanya
TAWN -yuh (not TAN)
Consonant Sounds
B
(BED) bed
TS
(ITS) its (PITS - feeld) Pittsfield
D
(DET) debt
TH
(THEI) Thigh
F
(FED) fed
TH
(THEI) Thy
G
(GET) get
ZH
(A- zhuhr) azure (VI- zhuhn) vision
H
(HED) head
Z
(GOODZ) goods (HUH - buhz -tuhn) Hubbardston
HW
HWICH which
J
(JUNG) jug
K
(KAD) cad
L
(LAIM) lame
M
MAT mat
N
(NET) net
NG
SING -uhr singer
P
(PET) pet
R
RED red
S
(SET) set
T
TEN ten
V
(VET) vet
Y
YET et
W
(WICH) witch
CH
I (CHUCRCH) church
SH
I (SHEEP) sheep
NOTE: This page should not be submitted to the filing officer.
Page 2, DS -DE 25 (Rev. 5/11) Rule 1S- 2.0001, F.A.C.
Candidate Name
Pronunciation Request
OFFICE SOUGHT: 'T-0Mj GOMH 1551 ONE - GOLF 9M EA M
Name On Ballot
bONNA S. WHITE DAV�-NA
Pronounced As
S. vV F- l T
Pronunciation Guide
• In the "NAME ON BALLOT" column, enter the name as it appears on your ballot (First,
Middle, Last).
• In the "PRONOUNCED AS" column, enter the breakdown using the PRONUNCIATION
KEY below. Capitalize STRESSED syllables, use lower case for unstressed syllables.
• You should also add any notes such as rhyming examples, silent letters, etc. Also
provide pronunciations for ambiguous place names, first names and surnames. Use
dashes ( -) to separate syllables.
Samples
NAME ON BALLOT
PRONOUNCED AS
William Mishaud
mee -SHO (V is silent)
Sue Jahn
HAHN (rhyme: fawn)
Tim Beauprez
boo -PRAT (rhyme: hooray)
Robert Maniscalco
man- uh- SKAL -ko
Tangipahoa
TAN- ji- pah -HO -uh
Monte Anthony
mahn TAI
Tanya Smither
TAWN-yuh (not TAN)
DS -DE 105 07/10
PRONUNCIATION KEY
Stressed Vowel Sounds
EE
(FEET) feet
I
(FIT) fit
E
(BED) bed
A
(KAT) cat (KAD) cad
AH
(FAH -thur) father (PARR) par
AH
(HAHT) hot (TAH -dee) toddy
UH
(FUHJ) fudge (FLUHD) flood
UH
(CHUHRCH) church
AW
(FAWN) fawn
U
(FUL) full
00
(FOOD) food
OU
(FOUND) found
O
(FO) foe
El
(FEIT) fight
Al
(FAIT) fate
OI
(FOIL) foil
Y00
(FYOOR- ee -uhs) furious
Unstressed Vowel Sounds
uh (SO -fuh) sofa (FING -guhr) finger
Certain Vowel Sounds with R
AHR (PARR) par
ER
(PER) pair
IR
(PIR) peer
OR
(POR) pour
OOR
(POOR) poor
UHR
(PURR) purr
Consonant Sounds
B (BED) bed
TS
D (DET) debt
TH
F (FED) fed
TH
G (GET) get
ZH
H (HED) head
Z
HW (HWICH) which
J
(JUNG) jug
K
(KAD) cad
L
(LAIM) lame
M
(MAT) mat
N
(NET) net
NG
(SING -uhr) singer
P
(PET) pet
R
(RED) red
S
(SET) set
T
(TEN) ten
V
(VET) vet
Y
(YET) yet
W
(WICH) witch
CH
(CHUCRCH) church
SH
(SHEEP) sheep
(ITS) its (PITS - feeld) Pittsfield
(THEI) Thigh
(THEI) Thy
(A- zhuhr) azure (VI- zhuhn) vision
(GOODZ) goods (HUH - buhz -tuhn)
Hubbardston
TOWN OF GULF STREAM, FLORIDA
ELECTION -MARCH 11, 2014
NOTICE TO CANDIDATES
The Logic and Accurace (L & A) Test of the tabulating equipment that will be used to
tabulate the ballots will be held at 3:00 P.M. on Friday, February 21, 2014, at the
Supervisor of Elections Facility at 7835 Central Industrial Drive, Riviera Beach, Florida,
33404.
If you plan to have a poll watcher /s, the name /s must be turned in to the Gulf Stream
Town Clerk's Office, 100 Sea Road, Gulf Stream, Florida 33483 no later than February
25, 2014, Tuesday, at 12:00 Noon.
The deadline for receiving campaign contributions is midnight, March 6, 2014 for
opposed candidates.
The deadline for receiving campaign contributions is noon, February 11, 2014 for
unopposed candidates.
This is to acknowledge that I have received a copy of this NOTICE TO CANDIDATES.
g► Rol+
Date Signature of andidate
OP F�
Co
N OF PA
Palm Beach County
SUSAN BUCHER
Supervisor of Elections
CERTIFICATION
240 SOUTH MILITARY TRAIL
WEST PALM BEACH, FL 33415
POST OFFICE BOX 22309
WEST PALM BEACH, FL 3341 B
TELEPHONE: (5611656-6200
FAX NUMBER: [561) 656 -B2B7
WEBSITE: www.pbcelections.org
I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do
hereby certify that Donna White submitted 6 petition signatures for the office of Gulf
Stream Town Commissioner.
I further certify that 4 of those signatures are registered electors in the Town of Gulf
Stream, according to the registration records on file in this office.
This is to further certify that Donna White is a registered voter in Precinct 4072, in the
Town of Gulf Stream, Florida.
Si ed, this the 10th day of February, 2014.
SUSAN BUCHER
SUPERVISOR OF ELECTIONS
PALM BEACH COUNTY
s
A
A
(SEAL)
CANDIDATE PETITION /�
Notes: -All information on this forrn becomes a public record upon receipt by the Supervisor of Elections. J
- It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes]
- If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form.
I, Vhi a rnfl�ftt''`_ the undersigned, a registered voter
(print name as it appears on your voter information card)
in said state and county, petition to have the name of lbn MW-A Cj , Wb R
placed on the Primary/General Election Ballot as a: [check/complete box, as applicable]
Nonpartisan ❑ No party affiliation ❑
Party candidate for the office of
(insert title of office and include district, circJit, group, seat number, if applicable)
Date of Birth or Voter Registration Number Address
(MM /DD Y)
�) t
City County State Zip Code
Cr��S�t�r►� ��r�w, 6x�.1� �- 3:�y��
Signature. f Voter Date Signed (MM /DDNY)
[to be com leted by Voter]
';z I d� �;
Rule 1S- 2.045, F.A ___ DS -DE 104 (Eff. 09/11
CANDIDATE PETITION
Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections.
- It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes]
- If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form.
the undersigned, a registered voter
(print name as it appears on your voter information card)
in said state and county, petition to have the name of (Dw IV 7g S ; I 1
placed on the Primary/General Election Ballot as a: [check/comp lete box, as applicable]
Nonpartisan ❑ No party affiliation ❑
(insert title of office and include
Date of Birth or Voter Registration Number
(MM /DD/YY)
Party candidate for the office of
district, circuit, Croup, seat number, if applicable)
Address
City County State Zip Code
Signature of
Date Signed (MM /DDNY)
bgrnpet/ -by Voter]
Rule 1S- 2.045, f.A.C. / k / r-A 1,F1 I/ C.+ DS -DE 104 (Eff. 0911
CANDIDATE PETITION /
Notes: -All information on this farm becomes a public record upon receipt by the Supervisor of Elections. it 7l
- It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes]
- If all requested information on this farm is not completed, the form will not be valid as a Candidate Petition farm.
W Al GE�J the undersigned, a registered voter
(print name as it appears on your voter information card)
in said state and county, petition to have the name of Donna S. White
placed on the Primary/General Election Ballot as a: [check/complete box, as applicable]
® Nonpartisan ❑ No party affiliation ❑ Party candidate for the office of
Town Commissioner, Gulf Stream
(insert title of office and include district, circuit, group, seat number, if applicable)
Date of Birth or Voter Registration Number Address
(MM /DD/YY)
01 -05 -36 1443 N. Ocean Blvd. Gulf Stream,
City County State Zip Code
Gulf Stream Palm Beach FL 33483
Sign re o V te U j
4J
� Rule 1S- 2.045, F.A.C.
Date Signed (MM /DDNY)
[to be completed by Voter]
_�L/7
DS -DE 104 (Eff. 09/11
CANDIDATE PETITION
Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections.
- It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes]
- If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form.
I, 11 to 0.zi�� Ir ey,) , 4 ccv the undersigned, a registered voter
�C (print name as it lappeYarss on your voter information card)
in said state and county, petition to have the name of DONNE S V V H IT
placed on the Primary/General Election Ballot as a: [check/complete box, as applicable]
%Nonpartisan ❑ No party affiliation ❑
Rul
Party candidate for the office of
i Q1tMMISSI0Nl�'1z . G UI_�: S7
(insert title of office and include district, circ It, group, seat number, if applicable)
Date of Birth or Voter Registration Number Address
(M /DD/YY) _
v 3
city County State Zip Code
Signature of Voter
J4��-
9Q? nAC C A P
Date Signed (MM /DDNY)
[to be corrmpleteGl by Voter]
104 (Eff. 09/11
CANDIDATE PETITION NIl�_ _T5_
Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections.
- It is a crime to knowingly sign more than one petition for a candidate. [Section 10=1.185, Florida Statutes]
- If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form.
1. the undersigned, a registered voter
(print name as it appears on your voter information card)
in said state and county, petition to have the name of D C) N N 4 S.
placed on the Primary/General Election Ballot as a: [check/complete box, as applicable]
Nonpartisan ❑ No parry affiliation ❑
Party candidate for the office of
TO W w C'OM A SS t DNER e7.,O(.�:: 5-TiZIF-A H_
(insert title of office and include district, circuit, group, seat number, if applicable)
Date of Birth or Voter Registrations Number Address
(MM /DD/YY) _ � / _ /
Ci County State` Zip Code
Signature of Voter
Rule 1S- 2.045, F.A.C.
Date Signed (MM /DDNY)
[to be compl ed b Voter]
79
DS -DE 104 (Eff. 09/11
CANDIDATE PETITION �j (R,
Notes: —411 information on this form becomes a public record upon receipt by the Supervisor of Elections.
- It is a crime to knowingly sign more than one petition for a candidate. [Section 101.185, Florida Statutes]
- If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form.
I• /'' �0 I ( vi -�— 6 q L -/d 1Z -�- the undersigned, a registered voter
S (print name as it appears on your voter information card)
in said state and county, petition to have the name of i. n K 1\ ! A S, W t"1 I FF
placed on the Primary/General Election Ballot as a: [check/complete box, as applicable]
san ❑ No party affiliation ❑
Party candidate for the office of
(insert title of office and include district, circuit, group, seat number, if applicable)
Date of Birth or Voter Registration Number Address
(MM /DD/YY)
Ci County State Zip Code
�� a vi 112c( e 1, F �073�If3
Signature of Voter /
Date Signed (MM /DDNY)
[to by Voter]
Yq
DS -DE 104 (Eff. 09111