Petition Drop Off Cantor0
M IAM I -LADE
'6-`
Miami -Dade Elections Department
2700 NW 871h Avenue
Miami, Florida 33172
305-499-8363
Petition Drop -Off Receipt
(To be completed when receiving petitions from Governmental Agency or Committee)
Name of Representative
I Petitions for
Quantity reported
has surrendered to Miami -Dade Elections Department
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: i00So N(&2-r)cfCiVf
ro t a M
Phone # Email Wiling Address
Petitions surrendered by: (Governm tal Agen or mmittee Staff)
Print Name Siq ature Date
Received by: (Miami -Dade Elections Department Staff) ,
Print Name Signature Date
DATE STAMP:
"Provide,a completed copy to Registration Manager*