DSDE9 Appointment of Campaign Treasurer- WAGARAPPOINTMENT OF CAMPAIGN TREASURER
02-12-19 1 1 :31 RC VD
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
officer before opening the campaign account.
OFFICE USE ONLY
1. CIjECK APPROPRIATE BOX(ES):
Initial Filing of Form Re- filing to Change: ❑ Treasurer /Deputy E] Depository ❑ Office Party
2. Name of Candidate (in this order: First, Middle, Last)
3. Address (include post office box or street, city, state, Zip
C r SiC. I M. VVC1 G V—
code)
q,..{.. p N E 9 5a-h S�vPe�i-
Mlai -Y„ S��orPs� FL. 3313
4. Telephone
5. E -mail address
0 335 -9s�3
(3 5)
c.0onno✓w4y4r�9wtia,l• �c
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
applicable:
Co UnCI I Item be✓
0 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 E] 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
(2- d r i'G M C- M, r) n
11. Mailing Address
12. Telephone
Ro. Box 17CZ2(�
( 7 16 (z ) Z2)1-4 Z 33
13. City
14. County
15. State
16. Zip Code
17. E -mail address
OfQlecih
Mrgmi- DQGL2,
FLT
3301-7
C c r g1'1.con n
18. 1 have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank
20. Address
84n k o Arner,'caL
9,fc 9 A/E Zed Aveoue.
21. City 22. County
23. State
24. Zip Code
MiaM,/ Shares M1am1' -Dade_
FLL,
33 1'3'8
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. Sign r f_ an date
27. Treasurer's Acceptance of Appointment (fill in the b nks and check the ap riate block)
I Ced vic. M C M1' r-) n , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer ® Deputy Treasurer.
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C.