DS-DE 9 1 Dave Crystal APPOINTMENT OF CAMPAIGN TREASURER �'���
I '
AND
DEPOSITORY TFOR OF
CANDIDATESN 201J4N2 �� S �� p� 2 . � O
(Section 106.021(1), F.S.)
CITY CLERK'S OFFICE'
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1 HECK APPROPRIATE BOX(ES):
Initial Filing of Form Re- filing to Change: Ei Treasurer /Deputy ❑Depository 0 Office El Party
2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip
t)o, v-e_ c ry 51 (
V 0 & X 1
4. Telephone 5. E -mail address / 6-c4 I (---c_ 3 1,1/
( r2co woi c irt 50. ove f_____________4________________ ,
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
/� applicable:
YM G Ov o 1- / 01 ( ( 3 e f�G4 E 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
E1 Write -In El No Party Affiliation 0 / v/A Party candidate.
9. I have appointed the following person to act as my Q' Campaign Treasurer El Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
:ii Sc;'ec Roseoivi,...1
11. Mailing Address 12. Telephone
* L K - S€Vc4\ Ave , 14 I a- 3 (30c ) Y3Y-- 4)- 3 7 C
13. City 14. County 15. State 16. Zip Code 17. E -mail address
. 2 1‘6, ; g"'"C' C / i -- 1° ` 12 - F L 3 31 v 0
A.........
18.1 have designated the following bank as my Q Primary Depository El Secondary Depository
19. Name of Bank 20. Address
'T D g c‘,4 coo Co(( s A ire
21. Cit 22. County 23. State 24. Zip Code
(`6 (eo.c(- ( ' 0 , 0 0 i — 1)4 '‘- 5 / 3 9
/ UNDER PENALTIES OF PERJURY, t DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT TME FACTS STATED IN IT ARE TRUE.
l
25. Date i 26. Signature of - - didate
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I � 56,6„.(_ R o S.-.2e I , do hereby accept the appointment
(Please Print or Type Name)
designated above as: El Campaign Treasurer 111 Deputy Treasu er.
1 1 i )- c/( I
Date Sig ature of Campaign Treasurer or Deputy Treasurer
---- ,4 , , /741-14,_
DS -DE 9 (Rev. 10/10) Rule IS-2.0001, F.A.C.