HomeMy WebLinkAboutAppointment of Campaign Treasurer RR - Refiled 08-12-2016APPOINTMENT OF CAMPAIGN TREASURER
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AND DESIGNATION OF CAMPAIGN
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DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
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NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
E] Initial Filing of Form Re -filing to Change: ATreasurer/Deputy ;K Depository ❑ Office ❑ Party
2. Name of Candidate(inthis order:First, Middle, Last)
3. Address (include post office box or street, city, state, zip
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4. Telephone
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5. E-mail address
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6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
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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 D No Party Affiliation ® Party candidate.
9. 1 have appointed the following person to act as my '�" Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Tre surer
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11. Mailing Address
12. Telephone
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13. City
14. County
15. State
16. Zip Code
17. E-mail address
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18. 1 have designated the following bank as myjjPrimary Depository Secondary Depository
19. Name of Bank
20. Address 516L-
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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
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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, Q o4 � P Pi k&/Ls , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
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Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.