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.
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OFFICE USE ONLY
1. C-1ECK APPROPRIATE BOX(ES):
El Initial Filing of Form Re -filing to Change: Treasurer/Deputy Depository Office Party
2. Name of Candidate (in
c-eCtnck -1-• �'
this order: First, Middle, Last)
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3. Address ((iinccllude�+pos�t/office/box or street, city, state, zip
code) yip �(J J • f..1 r f•-nlan (d •
4. Tele 1phone
( `to7 )8/Q-7,4 13
5. E-mail address
NIk norsLi1p yam, I . C -0"-N
34 • 10 -7
a" IAd3 I -F I . g2.57)
6. Office sought (include district, circuit, group number)
r1l-'J) CH►r • -Ptc4-(5)
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 Vi No Party Affiliation ❑ Party candidate.
9. I have appointed the following person to act as my ErCampaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
11. M ing Address
930 P1/4,-I,►,iLn (-.
12. Telephone
G21 ) mD597
13. City lj
0�Ik^Mk,
14. County
('jrour.st---
15. State
F I
16. Zip Code
3'2 o S
17. E -ma I address
G.1,lIabine.atTb4,1 • r=orh
18. I have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank
20. Address
21. City
Ov Ian DO
22. County
6►-e e...-
23. State
r I
24. Zip Code
3241
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 )zb 2i
26. Signature of Candidate
X -• ii..y20
27. Treasurer's Acceptance
I, 40‘,/).2/( c,
j
of Appointment (fill i t blanks and check the appropriate block)
1 , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
X
Date Signature of Campaign Treasurer or Deputy Treasurer
WOO
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.