Petition Drop off Charles1
OFFICIAL RECEIPT
MIAMI o No. 8053562
® MIAMI-DADS COUNTY—FLORIDA p2,� 7
RECEIVED FROM__fC-��l!'�!'�d DATE
r� r MONTH DAY YEAR
ADDRESS �r�r� Me 2 " Oc�v, CASH $
STREET ADDRESS
CHECKS $
------ . CITY STATE ZIP
AMOUNT OF:/ r DOLLARS, AND �� CENTS TOTAL $ �v �L�•
FOR PAYMENT OF:
THIS RECEIPT NOT V LID LESS DATED, COMPLETED AND SIGNED
%BY
DEPT.' G� " LESS DATED,
c _ems BY: G
FOR OFFICE USE ONLY
TRANS SUBSIDIARY INDEX CODE
or
HORIZED EMP EE OF DEPARTMENT.
SUBOBJECT AMOUNT
M IAM I•DADE
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)
OVW a)4\1 I has surrendered to Miami -Dade Elections Department
Name of Representative
100 7�Vu,�G C h a Y. )�S
Petitions for
Quantity reported
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: n
S -7�P - �l o-_ c; i Ct plc 2hcY al ✓ev)
Phone #
(( v ( z. z . cp) ryl�s �r�l
Email
Petitions surrendered by: (Governme
Print Name
or
(1J✓
Mailing Address
m ittee Staff)
Sig0ture
mj'ornM sho✓'O'ZiT/33)
Date
lt,
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Received by: (Miami -Dade Elections Department Staff)
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