DS-DE 9-1 Michael Gongora 2017APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
NOT S:--T-his-form must be on file with the qualifying
officer before opening the campaign account.
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OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re- filing to Change: ► Treasurer /Deputy 1 Depository [] Office ® Party
2.. Name of Candidate (in this order: First, Middle, Last)
/L4 t r1 U�°Il"1 i1ail L`% •0Vi V'C(.,
3. Address (include post office box or street, city, state, zip
code) s838, Ct?� /lh),1�5; . is , .
At an ,; 1 "�=`.c' �j ?/ `9'O
4. Telephone
( 3 3 s - - )Z —1 („1 .
5. E -mail address
/lid -r:( W1rd,ti r ✓,c.:.a1i".
6. Office sought (include district, circuit, group number)
1 614I gC4e11 Co o-dSg;ov) G ou
7. If a candidate for a nonpartisan office, check if
applicable:
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
•i
Party candidate.
9. I have appointed the following person to act as my 01 Campaign Treasurer ® Deputy Treasurer
10. Name of Treasurer or eputy Treasurer
`
11. Mailing
Address
1 30 l- ili 'er Dr
12. Telephone
( 3os ) cr) s- q]3
13. City
.
14. County
. u Dk
15. State
J
16. Zip Code
314)
17.
ma I address
d a -hwm grerai1, C
18. I have designated the following bank as my /Li Primary Depository ❑ Secondary Depository
19. Name of Bank .j. r
C[-kt fC)l lL
20. Address
.:J(,O 1) st
21. City C't n 1
22. ounty
23. State
24. Zip Code
UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 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
X .
27. ; Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
imJ A �I , do hereby accept the appointment
(Please Print or Type Name)
designated above as: 0 Campaign Treasurer • Deputy Trea urer.
.) �l ► X
Date Signature of Ca paign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S- 2.0001, F.A.C.