DS-DE 103 Preserve Miami Beach v
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ELECTIONEERING COMMUNICATION r
STATEMENT OF ORGANIZATION 1-17
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OFFICE USE ONLY
1. Full Name of Organization Telephone
Mailing Address (include city, state and zip code)
15 � � 14-0 i�'ca d --& (' I
Street Address(include city, state and zip code)
FL-- 33 1
2.Affiliated or Connected Organizations
Name of Affiliated or
Connected Organization Mailing Address Relationship
3. Area, Scope and Jurisdiction of the Organization
NI 10LW11 Cr
4. Identify by Name, Address& Position,the Custodian of Books &Accounts for the Organization
Full Name Mailing Address Street Address Title or Position
�e �i►2to` 10�-X4 V'r r�ravj
6WA16(es FL-
�313
5. This Organization was formed (check applicable box): (Calendar quarters end the last day of March,June,
DAember, and December.)
s a newly created organization during the current calendar quarter.
❑ From an organization existing prior to the current calend rter.
Form DS-DE 103(Rev. 08110) (continued on reverse)
6. List By N ame, Mailing and Street Ad ss & Position Other Principal Oficers in lu in g 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?
W�r'4
8. List All Banks, Safety Deposit Boxes, or Other Depositories Used by this Organization for Electioneering
Communications
Name of Bank or Depository Mailing Address
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d-O o U Fo^,,e, be, L&-a h '�WJ—
C ,,k &"u-j , FL- 33 134
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 F L O R.d t�I(+ NA;r COUNTY
I � 6L-41-(1ak--- , certify that the information in this Statement of
Organization is complete, true, and correct.
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Signature of Top ra g Prin ipal Officer of Organization Date
Form DS-DE 103(Rev.08/10)—page 2 of 2 Note: If necessary, continuation sheets should be used to complete the form.