Application of electronic filing BurchMWn1i Shares Village
Application and Acknowledgement of Electronic
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Filing Information
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1. CHLCK APPROPRIATE HOMES)
N Candidate 19 Treasurer/Deputy ❑ Commiltee Cl Committee Treasurer
?. Name of Candidate, Committer (First, Middle, Last)
3. Address {include P.O_ box or street, Villagc, state.
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zip code)
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4. Telephonep S. &mail address (
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Canipal_wi ftnwice ULt141[\' Ilia)' be filed %kith the Village Clerk using the CledfulllC Calnllaign finU1WC ILIMEIlle s)'Slcnl available
Online aF 1i1111s._aU:1 I111sb U1154111J t�_l_I'f1``'UILl:7C11��;itRf111n311LL.tipt1E llllt " jilt llt'I.
Credentials to log into die System wC JlllXU%-Ld On all ittelividual bjsls and nlay IWl be ihaled--c\'eft With n), tnil1Cf Of llle Sallie Calllhal_L',Il
Or eunlnduce. Each user who Is apllluved fur a"fedoitlals is responsible for JMUECC[Ill� those Cl ellen[IaIS flulri disclosurL Ur Cutllpfunlisc.
Once Cleden[Ials have been approeed fur a nave. Out Elsa) Is de'Crl)Cd iesponsible for cke'rV repurt filed using Lllose Credentials until
such f me as the Villa�c Clerk is maified of diieloswc or cunlptuniise uflhusC CICdCntlils. Calllpal ell Of L'U lllnlll[CC Il1uS1 Inlllledla[Cly
nollf)' the Village Clelk If ally User associated Aith that canipaign ul ConitAlwc beLonws Ineligible to hold the credentials issued to
Thal user.
Each report must be flied before nddolght at the end of the due date. Reports that have been need late are subject to ones
pursuant to Florida Statutes sectbos 111b,07(8) or 106.I9(4 as applicable.
By filing a report through the S)sieni� a person (r) is dine Il to hake eleelronically sighed [b! repurl under oath and lu Ilaye LeltlfiUd
1he o 11CLE esS of the tepoit in accordalfce with Florida Statutes sections 106.070) or L06.2912i. as applicable: (iii is lespo&siblc fur
The accuraLy' and aelacily Of the report, and liiil conunits a Clinlinal act by certifying J report that Is knuwn to h, InLon CCt, fake. or
incwnip loc.
A lepoft is cleansed filed wii IL the Villi�e t lefk Unly when [be System issues a Icceipl cullfilllling Elie dale and tulle at Which Elie
fepurt Was filed. The s)5leni Will issue a sepaiaic notice for the subsegLwnt aeCclltanCe Or rejCCtiUn of the relxllt by the Village Clerk.
Once a tepoit his been filed With llle Village Clerk, it Ilia)' be changcd only b4 filing an alllendinent to lhal repim.
The Village is not respunslble fur providing the inicniel ac Less necessiuy ELI access the Sysleni, and prolilents lyllh all uidtyldual
candidate's Iltterrlet JCCLYs at a ILsidence, office. CuffCC shop, C[L. do not excuse late filing by Out eandidale. The Village Clerk Will
Provide Fill alternate filing deadlllle fur candidates only in the cvetit that the Reporting Systeni is Keejowlk inupefahle and all
candidates filing via electiunic male. are an'ecled.
UNDER PENALTIES OF PERIURV. 1 DECLARE THAT I HAVE READ AND UNDERSTAND THE FOREGOING
FORA FOR APPLICATION _ ND ACKNOWLEDGEMENT OF ELECTRONIC FILING INFORMATION AND THAT
THE FACTS STATED 1N IT ARE TRUE,
G. Date 7_ Siggn�alnrreofCandidat ''otritrulteeChair
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X. Treasurer's Application and Acknontedkement of Electronic Filing Information (fill in the blanks and check
the a propnate block)
I, C. (printed name), F • •by aeknowledce that [ ant representing
the Candidate -Committee alcove as the ❑ Campaign Ttz• . r D •pun Treasurer
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Date i4lta re of Treasurer• or Deputy Trewsaw`r
001%111