Forms DS-DE 41 and 103I
REGISTERED AGENT OFFICE USE ONLY L..
STATEMENT OF APPOINTMENT
(Section 106.022, F.S.) 2014 DEC it; 10:
„Jr( C1 ,, 'S OFF ICE
5 Original Appointment ❑ Change of Appointment
❑ Change of Mailing Address ❑ Change of Physical Address
Registered Agent and Office Information
Name Telephone
Mark Herron 850-567-4878
Street Address
2618 Centennial Place
City State Zip Code
Tallahassee FL 32308
Mailing Address
P.O. Box 1701
City State Zip Code
Tallahassee FL 32302-1701
I accep∎ this ap••intment and confirm that I am familiar with and accept the obligations of the position as set
forth in Sectio 06.022, F.S. I also understand that I may resign this appointment by executing a written
statem•n^• r: • ation and filing it with the applicable filing officer.
AA ,� 16 December 2014
Signat e of -egistered Agent Date
Former Registered Agent and Office Information (for changes only)
Name Telephone
Street Address
City State Zip Code
Committee or Organization Information
Name of Committee or Organization
Miami Beach Advisory Council
Street Address Telephone
2618 Ce tennial Place 850-567-4878
City State Zip Code
Tallahass-e FL 32308
Signat e of C airperson
Mark Herron 19 December 2014
Printed Name of Chairperson Date
Form DS-DE 41 (revised 6/11)
ELECTIONEERING
COMMUNICATIONS ORGANIZATION
STATEMENT OF ORGANIZATION
(PLEASE TYPE)
OFFICE USE ONLY
1. Full Name of Organization Telephone
Miami Beach Advisory Council 850-567-4878
Mailing Address (include city, state and zip code)
Post Office Box 1701 , Tallahassee, FL 32302-1701
' Street Address(include city, state and zip code)
2618 Centennial Place, Tallahassee, FL 32308
2.Affiliated or Connected Organizations
Name of Affiliated or
Connected Organization Mailing Address Relationship
1 None
3.Area, Scope and Jurisdiction of the Organization
To engage in electioneering communications regarding candidates in Miami Beach.
4. Identify by Name, Address& Position,the Custodian of Books&Accounts for the Organization
Full Name Mailing Address Street Address Title or Position
Mark Herron Post Office Box 1701 2618 Centennial Treasurer
Tallahassee, FL Place, Tallahassee,
32302-1701 FL 32308
5. This Organization was formed (check applicable box): (Calendar quarters end the last day of March,June,
September,and December.)
km As a newly created organization during the current calendar quarter.
From an organization existing prior to the current calendar quarter.
Form DS-DE 103(Rev.06/11)—Rule 1S-2.017 (continued on reverse)
a 4
6. List By Name, Mailing and Street Address, & Position, Other Principal Officers, including the treasurer and
deputy treasurer, if any. Include the top-ranking officer's(e.g., chairperson) name and information.
Full Name Mailing Address Street Address Title or Position
Mark Herron Post Office Box 1701 2618 Centennial Chairman &
Tallahassee, FL 32302-1701 Place, Tallahassee, Treasurer
FL 32308
7. In the Event of Dissolution,What Disposition will be Made of the Residual Funds?
Residual funds will be contribution to an IRC 501(c) organization or an IRC 527 organization.
8. List All Banks, Safety Deposit Boxes,or Other Depositories Used by this Organization for Electioneering
Communications
Name of Bank or Depository Mailing Address
SunTrust Bank 3522 Thomasville Road
Tallahassee, FL 32309
9. List All Reports Required to be Filed by this Organization with Federal Officials, &the Names, Addresses,
& Positions of Such Officials, If Any
Report Title Dates Required to be Filed Name&Position of Official Mailing Address
RS Form 8871 Upon Creation IRS Ogden, UT 84201
IRS Form 1120-POL March 15 Annually
IRS Form 990 May 15 Annually
STATE OF Florida Leon COUNTY
I
Mark Herron , certify that the information in this Statement of
Organization is compl-,.e, true, and correct.
4.4.1 19 December 2014
Signatu of To•-ranking Principal Officer of Organization Date
Form DS-DE 103(Rev.06/11)—Rule 1S-2.017-page 2 of 2 If necessary,use continuation sheets to complete the form.