DS-DE 9-2 Michael Gongora 2017APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
�
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
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of 4i ' ,- 1 P;�
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
❑ Initial Filing of Form Re- filing to Change: a Treasurer /Deputy Depository ® Office ❑ Party
2. Name of Candidate ((in this order: First, Middle, Last)
M i laef kr S11Ct/1 Gene- r
3. Address (include post office box or street, city, state, zip
code) s 8.58 GI, 1fr- 61f. 43A,
H; ' rG''l , 'E - 331-/-0
4, Telephone
( 3 °s ) 260- ) 0 / LI-
5. E -mail address
ill iC.G'Ve1 Q n�, c c li «�.1 ..e_zw.�..
6. Office sought (include district, circuit, group number)
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7. If a candidate for a non artisan 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
Party candidate.
9. I have appointed the following person to act as my ❑ Campaign Treasurer Ei Deputy Treasurer
10. Name of Treasurer or Deputy r.�easurer
Mi ci-)4 1 } �o of n 171,-63,
11. Mailing Address
1I, - 3A
12. Telephone
(30,) 0-/01
13. City
M k rvl reca-
14. County (�
Ail-
R114 `�' ?�P
15. State
PL..
16. Zip Code
33 )1
17. E -ma I address
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18. I have designated the following bank as my 11 Primary Depository ❑ Secondary Depository
19. Cr'
of B11a
\nnk} 111 /� / 9/
20. Address
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21. City
tC�i �%I &CO')
22.
County
iGvu (I'' 0 do.
23. St �e
'-
24. Zip Code
3 3 ) 9 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 o Candid
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27.
I,
Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
�c�,(.0/'Vel 6 ° (()?/.. , do hereby accept the appointment
(Please Print- ype Name)
designated above as: ® Campaign Treasurer
1,-_,H 1 1.- x
Deputy Tre surer.
\ _
Date
Signature of Campaign Treasurer e uty Treasurer
DS -DE 9 (Rev. 10/10)
�.i Rule 1S- 2.0001, F.A.C.