DS-DE 9 5 D. Crystal APPOINTMENT OF CAMPAIGN TREASURER F D
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES 2013 AUG -9 PH 12: 42
(Section 106.021(1), F.S.)
CIT)' CLLEIRi"'`j OFF ICE
(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
2. Name of Candidate(in this order: Firs , Middle, Last) 3. Address(include post office box or street, city, state, zip
k/�i code) a� Li s\I
4. Telephone 5. E-mail address
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6. Office sought(include district, circui , group number) 7. If a candidate for a nonpartisan office, check if
applicable:
C,(A, f�d�1 �� ❑ 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
10. Name of Treasurer or Deputy Treasurer ej �
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11. Mailing Address 12. Telephone
A ( 6) �49 z
13. City r 14. ount 15. State 16. Zip Code 17. E-m it address
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18. 1 have designated the following bank as my Ef Primary Depository Secondary Depository
19. Name of Bank 20. Address
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21. City 22. County 1 23. State 24. Zip Code
'/AL'At CAA JL o Ju, )C& 3313 �
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 C at
.L12 X
27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block)
do hereby accept the appointment
(Please Print or Type Name)
designated�bove as., Campaign Treasurer Deputy Treasurer.
g' / 3 X
__7/ Date Signature of Cam ign Treasurer or De uty Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.