DS-DE 84 Libbin C? N
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OFFICE USE ONLYr- n �
STATE1101ENT OF co 71
CANDIDATE ` , -'
(Section 106.023, F.S.) = -�
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candidate for the office of 17-,o�y1Z. ;
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
ignature of Candidate Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to.$1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS-DE 84(05/11)