DS-DE 84 Meruelo OFFICE USE ONLY
STATEMENT OF
CANDIDATE
(Section 106.023, F.S.) 2011 AUG 19 PM I' 49
(Please print or type) C I T Y CL ?': ',)
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candidate for the office of " , l , ? AeeiVA 2 /WOW- C/ '4'
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
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Signature of Candidate Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
- .e
- -t AUG 22 2011
DS -DE 84 (05/11)