DS-dAPPOINTMENT 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. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX (ES) :
Initial Filing of Form Re - filing to Change: Treasurer/Deputy Depository Office Party
3. Address (include post office box or street, city, state, zip
2. Name of Candidate ( in this order: First, Middle, Last)
code)
4. Telephone 5. E - mail address
( )
6 . Office sought (include district, circuit, group number ) 7 . If a candidate for a nonpartisan office, check if
applicable:
My intent is to run as a W rite - 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
_________________________________________ .
Campaign Treasurer Deputy Treasurer
9 . I have appointed the following person to act as my
10 . Name of Treasurer or Deputy Treasurer
11 . Mailing Address 1 2 . Telephone
( )
13 . City 1 4 . County 1 5 . State 1 6 . Zip Code 17 . E - mail address
Primary Depository Secondary Depository
1 8 . I hav e designated the following bank as my
19 . Name of Bank 20 . A ddress
21 . Cit y 2 2 . County 2 3 . State 2 4 . Zip Code
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.
2 5 . Date 2 6 . Signature of Candidate
X
2 7 . (fill in the blanks and check the appropriate block)
I, , d o hereby accept the appointment
(Please Print or Type Name )
designated above as: Campaign T reasurer Deputy Treasurer.
X
Date Signature of Campaign Treasurer or Deputy Treasurer
Rule 1S - 2.0 0 01, F.A.C.
DS - DE 9 (Rev. 10 /10 )