Statement of Candidate-BurchSTATEMENT OF
CANDIDATE
(Section 106.023, F.S.)
(Please print or type)
OFFICE USE ONLY
01 -17-19 1038 RC VD
CC
candidate for the office of IVVI 1� >��U�°1 ��► �l �j7��1 C�
a � ,
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
X A, �►
ignature of Candidate
1'17- [9
Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS -DE 84 (05/11)