DSDE-9- BurchAPPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
01 -17 -1 9 10 : 39 RC VD
officer before opening the campaign account.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
8 Initial Filing of Form Re- filing to Change: C] 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
41 cf . Up a1
code) 144a N E,� to 617
4. Telephone
5. E -mail address
(305 )NS q579
V b(trC ��a0).c0
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
}
I t7 G�
applicable:
[] My intent is to run as a Write -In candidate-
8. If a candidate for a ap rtisan office, check block and fill in name of party as applicable: My intent is to run as a
Q Write -In ❑ No Party Affiliation Party candidate.
9. 1 have appointed the following person to act as my Q Campaign Treasurer E] Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
�'0
fl`)G- I F W1 Ul AKSOtq
11. Mailing Address
t rf Io I
12. Telephone
z-:�!,5
(JOJS) Q
13. City
14. County
15. State
16. Zip Code
17. E -mail address
18. 1 have designated the following bank as my Q Primary Depository Secondary Deposito
19. Name of Bank x //
T D 6/QQ
20. Ad ress
q00
4%a�
21. City
IN �M
22. County
�AM � b4
23. State
_
24. Zip Code
�� c --�)V
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 q
26. Signat re of Candidate
,%X1Ja'
27. Treasurer's Acceptan a of Appointment (fill in the blanks and check the appropriate block)
r�
I, do hereby accept the appointment
(Please Print or Type Name)
designated a ove as:] Campaign Treasur eput Tre sur
ate I Signature of Campaign FreasVer or Deputy Treasurer
DS -DE 9 (Rev. 10 /10) Rule 1S- 2.0001, F.A.C.