Preserve Miami Beach ECO (7 N
O
ELECTIONEERING COMMUNICATION
STATEMENT OF ORGANIZATION =�
o �
(PLEASE TYPE)
cn
cn
OFFICE USE ONLY
1. Full Name of Organization Telephone
3r'r V& MICA-VK'I Bet"
Mailing Address (include city, state and zip code)
151 (4I- oe\ 1 ,Cad --*- GI
Street Address (include city, state and zip code)
'am I. 3312>c1
2. Affiliated or Connected Organizations
Name of Affiliated or Mailing Address Relationship
Connected Organization
3. Area, Scope and Jurisdiction of the Organization
Mlaw►l e�c�ln
4. Identify by Name, Address & Position,the Custodian of Books &Accounts for the Organization
Full Name Mailing Address Street Address Title or Position
J—C-" t0�'3-y ve*�r�avj S4
Lena l (x+.b(es IFL
7313`
5. This Organization was formed (check applicable box): (Calendar quarters end the last day of March,June,
7 Se tember, and December.)
As a newly created organization during the current calendar quarter.
❑ From an organization existing prior to the current calend rter.
Form DS-DE 103(Rev. 08/10) (continued on reverse)
6. List By Name, Mailing and Street Address, & Position, Other Principal Officers, including the treasurer and
deputy treasurer, if any. Include the top-ranking officer's (e.g., chairperson) name and information.
Full Name Mailing Address Street Address Title or Position
7. In the Event of Dissolution, What Disposition will be Made of the Residual Funds?
8. List All Banks, Safety Deposit Boxes, or Other Depositories Used by this Organization for Electioneering
Communications
Name of Bank or Depository Mailing Address
D 4 d-000
F-I-- 0 134
9. List All Reports Required to be Filed by this Organization with Federal Officials, &the Names, Addresses,
& Positions of Such Officials, If Any
Report Title Dates Required to be Filed Name& Position of Official Mailing Address
STATE OF FLDRd p✓k V'Uo":i COUNTY
certify that the information in this Statement of
Organization is complete, true, and correct.
X lL
Signature of Top ra g Prin ipal Officer of Organization Date
Form DS-DE 103(Rev. 08110)—page 2 of 2 Note: If necessary, continuation sheets should be used to complete the form.
REGISTERED AGENT OFFICE USE ONLY C=
0
STATEMENT OF APPOINTMENT 7
(Section 106.022, F.S.)
rT
Cri 1y,
® Original Appointment ❑ Change of Appointment cl = T
T1 o
❑ Change of Mailing Address ❑ Change of Physical Address T t11
Registered Agent and Office Information
Name Telephone
:1� �aa,r C, 3es— KaS ao r
Street Address
City � b� State r Zip Code3
Mailing Address
City State Zip Code
I accept this appointment and confirm that I am familiar with and accept the obligations of the position as set
forth in Section 106.022, F.S. I also understand that I may resign this appointment by executing a written
statement of resign ti n iling it with the applicable filing officer.
Signature of R ed Ag nt Date
Former Registered Agent and Office Information (for changes only)
Name Telephone
Street Address
City State Zip Code
Committee or Organization Information
Name of Committee or Organization
r .uv� M, C.ac�
Street Address Telephone
City State �L Zip Code S [3`l
Signature of Chairpe s
Printed Name of Chairperso Date
Form DS-DE 41 (revised 6/11)