DS-DE 9 1 Berke APPOINTMENT OF CAMPAIGN TREASURER R E C E i v E n
AND DESIGNATION OF CAMPAIGN 2011J4N28 PN 4. 08
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
CIT'I, CLERy OFFICE
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before • • �.::•- . -' - -,� • m ai�n account. � OFFICE USE ONLY ,
• 1 „C � y APPROPRIATE BOXES :
”. �;' Initial Filing of Form Re- filing to Ch Treasurer/Deputy [] Depository ❑ Office Ej Party
2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post offic� box r street, city, state, zip
9 Aex k'- code) � �D� c J��bC(�I c r , jc
4. Telephone 5. E -mail address )A tcn Qocti F -1-- 33( q/
I
( ) 5 ( -6y/4 . Oil
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
J�� applicable:
,/ " `akf Q 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
El Write -In Ej No Party Affiliation � VL ' ' `h`� (t i Party candidate.
9. 1 have appointed the following person to act as my g Campaign Treasurer El Deputy Treasurer
10: Name of Treasurer or Deputy Treasurer
! V \ 1614A e7C1 i
11. Mailing Address 12. Telephone
109 41-6 A .
t ciwti 6-vi /6 Or ( 50 ) q c (Y --. 7q (( Y
13. City 14. County 15. State 16. Zip Code 17. E -mail address r dk- 6 "rnAi t ) t 0
N 1 1 / 1 I A t A afrAl A" - t)4 °& ri'. 33 / V/ 18. I have designated the following bank as my El Primary Depository fl Secondary Depository
19. Name of Bank 0,m ie.- 20. Address I / 6� LJ cayrk, (1W
21. City t 22. County 23. State 24. Zip Code rt t 8 - /
4/. AA/46N frivt-mi---04:06- UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 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. Signature of C- dim aTor.t. _........_.•
1 (61,e 1/ x 27._ Treasurer's Acceptance of Appointment (fill in the blan I d ch-Or appropriate block)
I, W' (1 i L7rk , do hereby accept the appointment
(Please Print or Type Name)
designated above as: ii2r Campaign Treasurer El Deputy Treasurer.
/ - Z P - // X
Date S':, ature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) 7 Rule 1S- 2.0001, F.A.C.