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Candidate Signatures
MIA�MNDiADE Miami -Dade Elections Department 2700 NW 87th Avenue Miami, Florida 33172 305-499-8363 Petition Drop -Off Receipt (To be completed when receiving petitions from Governmental Agency or Committee) --T.-;© m C'-Du't i ---. Name of Representative Quantity reported has surrendered to Miami -Dade Elections Department Petitions for Candidate/initiative NOTE: Quantity reported is not official until counted by Elections staff. You will be notified if the official count does not match quantity reported. Provide the following for the Candidate or Initiative contact person in case we need additional information: 0 F Zr�c�(c ✓P� (Y11CA Y'11 S4cfs2.l�}-� 3 Phone # Email Mailing Address Petitions surrendered by: (Govern ntal Ago y or CorAftee staff) Print Name Sig ature Receive by: (Miami -Dade Elections Department Sta zi :_211312-,-3 Date In //--'3 /11) 1-1 _--'> M®OFFICIAL RECEIPT NO. 8053557 � MIAMI-DADE COUNTY-FLORIDA ' RECEIVED FROMZAI%�/ 1� DATE I7�� MONTH DAY YEAR 1Cf ADDRESS 62� r 1G e:?' CASH $ AMOUNT OF: STREET ADDRESS CHECKS $ l00. 40 DOLLARS, ANDCENTS TOTAL $ I/7y FOR PAYMENT OF: THIS RECEIPT NOT VALI=c-e ESS DATED, COMPLETED AND SIGNED BY A HORJZED EMPLD OF DEPARTME T. DEPT.: ! BY' FOR OFFICE USE ONLY lur.ul-i wur r � f CITY �P�t ►4 SUBSIDIARY INDEX CODE