DS-DE 9-1 MR Islam APPOINTMENT OF CAMPAIGN TREASURER R A! F F)
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES 2013 JUL 29 PM 1: 17
(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):
0 Initial Filing of Form Re-filing to Change: (Treasurer/Deputy 0 Depository ❑ Office ❑ Party
2. Name of Candidate(in this order: First, Middle, Last) 3. Address(include post office box or street, city, state, zip
code)
4. Telephone 5. E-mail addr ss f,,t o -Ivtl � �(�-�-• �1� 3 3� —
6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
applicable:
�-0l)P - ❑ 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. 1 have appointed the following person to act as my ❑ Campaign Treasurer Deputy Treasurer M ssz
10. Name of Treasurer or Deputy Treasurer
11. Mailing Address 12. Telephone
13. City 14. County 15. State 16. Zip Code 17. E-mail add ss
Mv'km V?F_AC . `I)A'D F_ to,60 nil c
18. 1 have designated the following bank as my ❑ Primary Depository ❑ Seco dary Depository
19. Name of Bank 20. Address
C 14A5f--' x-04 44I Z �OYrn 1e_
21. City 22. County 23. State 24. Zip Code
MtM 32)14- \
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. Signatu o andidate
C)4A X 1 �
127. 1 Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block)
1, �'40gw"f- %�LAM , do hereby accept the appointment
(Please Print or Type Name)
designated above as: ❑ Campaign Treasurer ty Treasurer.
d �� X --
a e Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.