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.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
bp�lj Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
... ,17
3. Address (include post office box or street, city, state, zip
code) i - f e4NDFD4D
4. Telephone
107 ) lie V-ckSa
5. E ail address
/vow Weikerp.i, , co/4
Q�//11J,a, `/. 3 24-2 7
6. Office sought (include district, circuit, group num l6tr)1
7. If a candidate for a nonpartisan office, check if
el of /4/4-Awd
#
CO Midi SS;&fa —` DiS e/
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 f1 Party candidate.
9. I have appointed the following person to act as my ❑ Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
17
11. Mailing Address
9r 79ff Rthwegp I
12. Telephone
(y%7) 991-5 's-6
13. City
D/e /4ttfl c
14. County
o2. - 6g
15. State
Pl.
16. Zip Code
32z7
17. E-mail address
R€/tea (,vt , cv,,
18. I have designated the following bank as my isz Primary Depository Secon and y [repository
19. Name of Bank
Co6ir 6'v
20. Address
llgo S. e,Mit5 191/e,. St. re. /se
21. City
44 bliUv0
22. County
4M4 Aid1- - -
23. State
C./04/A1
24. Zip Code
328 7
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. Signat - of C. ndidate
27. Treasurer's Acceptance of Appointment (fill in the '-.nks and check the app priate block)
r-1 7 re✓A , do hereby accept the appointment
(PleasePri or Type Name)
designated above as: Campaign Treasurer ❑ Deputy Treasurer.
7' /S X
Date Signa�of Campaign Tr surer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.