DS-DE 9 S. Berke APPOINTMENT OF CAMPAIGN TREASURER F 1 V F I1
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES 2013 JUIN 12 Phi 1: 04
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE) CITY CLERil,'S OFFICE
NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
2" Initial Filing of Form Re-filing to Change: ❑ Treasurer/Deputy ® Depository ❑ Office ❑ Party
2. Name of Candidate(in"this
�,order: First, Middle, Last) 3. Address(include post office box or street, city, state, zip
54we. &Q I t code) /�F-/ Alcf�. 4a 49, *,c r�
4. Telephone 5. E-mail address 13&G 3-313
5
�305_(0 DOSS-/ Je 4
6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office,check if
applicable:
/rl 0.,y o r ❑ 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 [D-<o Party Affiliation ❑ Party candidate.
9. 1 have appointed the following person to act as my ❑ Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
Ice
11. Mailing Address 12. Telephone
I cF e/ (30r ) 60a os�/
13. City /� 14. County 15. State 16. Zip Code 17. E-mail address
✓11 144A,' 6 egcC I'Z- 33/ 3 °M
18. 1 have designated the following bank as my Primary Depository ❑ Secondary Depository
19. Name of Bank S �� 20. Address
h/
21. City 22. County 23. State f 24. 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.
25. Date 26. Signa andi to
X
27. Treasurer's Acceptance of Appointment(fill in th tanks and check the appropriate block)
I, S-( � �� " do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Depu Treasurer.
h)-/,.) ) X
Date Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.