DS-DE 9 Bower Treasurer FD
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN 19 A� �� ` 3
DEPOSITORY FOR CANDIDATES NIB 140
(Section 106.021(1), F.S.) C ' , �� 1C
(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):
II initial Filing of Form Re- filing to Change: ❑ Treasurer /Deputy Ej Depository Ej Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip
code) f °1 sefiemenNe.
i gag ?.00t 4. Telepho e 5. E -mail address m e 6 . 47
(3D ) 3(. pia 1tiky3f / di a / 33139
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
applicable:
El My in i ra as a Write -In candidate.
8. If a candi ate for a partisan office, check block and fill in n me of party as applicable: My intent is to run as a
0 Write -In El No Party Affiliation Ei iV Party candidate.
9. I have appointed the following person to act as my RI Campaign Treasurer El Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer .
_IligAl_k____,ggiark7__ dTM,,if4' 2..
11. Mailing Address 12. Telephone
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13. City 14. County i 15. State 16. Zip Code 17. E -mail add
JY.g,ij,4 JI 513? /� / /}
18. I have designated the following bank as my 0 Primary Depository ❑ Secondary Depository r
19. Nam- of Bank • 20. Address
/ / '
./ _ -..,/ ../. / , /1 0 '__-li . .4 / g i i 'I r 4 ...j If s---
21. City, 22. County 23. State 24. Zi Code
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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
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P‘e
27. T easurer's ceptance of Appointment (fill in t e bllanks and check the appropriate block)
1 . - Tgl Z (......71 , do hereby accept the appointment
Y N�
(Please Print or Type Name)
designate above as: Campaign Treasure r` 0 - +ep'titty Treasurer.
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Dale , a ure of Campai ! n T - - surer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.