DS-DE 84 Crystal i
OFFICE USE ONLY
STATEMENT OF RE C F t V F n
CANDIDATE 2013 FEB 12 AM ll: 22
(Section 106.023 F.S.)
(Please print or type) CITY CLER"
I, aCJ�. ✓ a ,
candidate for the office of °` Sao ✓' ��a� -� ;
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
d
x J3
Signature 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(05111)