DS-DE 9 Raphaël Herman 0
APPOINTMENT OF CAMPAIGN TREASURER C= i E__
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
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(Section 106.021(1), F.S.)
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(PLEASE PRINT OR TYPE) °
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NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re-filing to Change: ® Treasurer/Deputy Depository ❑ Office ❑ Party
2. Name of Candidate(in this order: First, Middle, Last) 3.Address(include post office box or street, city, state, zip
R A PHA E-L_ Hj6-A HALE_ code) � r 3o �/9 V 77L-CJS DR ) VF
4. Telephone F'4x 5. E-mail address 1AA11 Br79 C# 19:Z0A1 DA .3314c)
(30,.7)C7q-8592__
6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
applicable:
d/� ® �I�/�1 ��� ❑ 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
® Write-In ❑ No Party Affiliation ® Party. candidate.
9. 1 have appointed the following person to act as my Campaign Treasurer ® Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer A P77AC_� 1141EW/"/P�
11. Mailing Address 12.Telephone
#-1,3C) 41,4V77�V-! /Z 1114)1//fl6�C# (.3 oS")e K 7�L L9,,5-b 12,
13. City 14. County 15. State 16. Zip Code 17. E-mail address
/4-f 09,H lahl?1 pA Ae:? FZ,- 5,31
18. 1 have designated the following bank as my X Primary Depository ❑ Secondary Depository
19. Name of Bank AUA,41& 20.Address l 0 ao SRI G /i
21. City 22. County 23. State 24. Zip Code
/1'1/h/I1 110RI - DAPE l DA 3313 l
UNDER PENALTIES OF PERJURY,I DECLARE THAT I 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 Candidate
2,013 _�
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27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block)
I, f2 A PIYA �- � �� , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
® 7 — 1 2-013 X --
Date Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.