DS-DE 9 Cindy A. Mattson 2017 •
p
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES. Nil FEB -9 9 FT 1 I: 59
(Section 106.021(1), F.S.) ,
CITY
(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):
® Initial Filing of Form Re-filing to Change: E] Treasurer/Deputy ® Depository ❑ Office EJ Party
2. Name of Candidate(in this order: First, Middle, Last) 3.Address(include post office box or street, city, state,zip
C1 06q Q a o.kk-SOrl
code)1700 w c i can Ade_, 403
4.Telephone 5. E-mail ad ss
Clh coksD eeocisn�t{ao.
c� (� �2_` "` c�i-nA �M tiadv4 . � L '3313`1
6. Office sought(include district, circuit,group numbery-.0 P 7. If a candidate for a nonpartisan,office,check if
/�
applicable:
M CA Cbrivki5atiolicir ❑ 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
ID Write-In El 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
Dr . Try
11. Mailing Address • 12.Telephone
1 000 8aMA Poinke Dri \re (3p5 ) 3\o - 38 5
13. City
14. County 15. State 16.Zip Code 17. E-mail address
1M* d3L.C�2C+ ► I V`GYti1 L, i . ) I 1 1n Q6, CA•r'cl,o cerfrmiarvN . wel•■
18. I have designated the following bank as my 1)3 Primary Depository El Secondary Depository
19. Name of Bank 20.Address
CO.1 ,\ ,r tiak IGnV cTrrSk- 55 P\ r>~ cc ?VGA
21. City 22. County , 23. State 24.Zip Code
(A ra■ Gables 11/W T301
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 r 26. Signature o idate
) 9JI 7
27. Treasurer's Acceptance of Appointment(fill in the blanks a d check the appropriate block)
I, \ no cifae , do hereby accept the appointment
(Pleas Print or Type Name)
designated above as: ttt Campaign Treasurer El Deg. 're-surer.
"l X !■
Ite' Signature/ Campaig reasurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.