DS-DE 9 Josef Jorczak ,1
Aft
APPOINTMENT OF CAMPAIGN TREASURER ° `�
AND DESIGNATION OF CAMPAIGN 2015 MAY -4 9. 3 ,
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.) C n' r ;_ ;_,,f_. ; OFF
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1.CHECK APPROPRIATE BOX(ES):
El Initial Filing of Form Re-filing to Change: ® Treasurer/Deputy ® Depository El Office ® Party
2. Name of Candidate(in this order: First, Middle, Last) 3.Address(include post office box or street,city,state,zip
Josef Jorczak code)
1632 Meridian Apt 312
4. Telephone 5. E-mail address Miami Beach, FL 33139
( ) 473-4573 JJCampaign @outlook.com
6. Office sought(include district,circuit,group number) 7. If a candidate for a nonpartisan office, check if
City of Miami Beach Commission Group V applicable:
0 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. I have appointed the following person to act as my ® Campaign Treasurer ® Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
Josef Jorczak
11. Mailing Address 12.Telephone
1632 Meridian Apt 312 ( 786 ) 473-4573
13.City 14. County 15. State 16.Zip Code 17. E-mail address
Miami Beach Miami-Dade FL 33139 JJCampaign @outlook.com
18. I have designated the following bank as my Primary Depository [] Secondary Depository
19. Name of Bank 20.Address
Bank of America 1632 Meridian Apt 312
21. City 22.County 23. State 24.Zip Code
Miami Beach Miami-Dade FL 33139
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
5/1/15 X _;,/YL-�
27. Treasurer's Acceptance of Appointment(fill n the bl nks and c eck the appropriate block)
l Josef Jorczak ,do hereby accept the appointment
(Please Print or Type Name) 3,
designated above as: ® Campaign Treasurer Deputy Treasurer.
5/1/15 X i
Date Sign re of Cam./f gn /asurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.