Petition Drop off Receipt Saint Fleurb\
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Miami-Dade Elections Department
2700 NW 87th Avenue
Miami, Florida 33172
305-499-8363
Petition Drop -Off Receipt
PA J 0T Ikit' . has surrendered to the Elections Department
Name oLf Representative
�J Petitions for acc irk F142 0Y.
Quantity Candidate/initiative
Should the need arise to contact Candidate, please provide us with Candidate's:
Phone #
Email
Mailing Address
Petitions surrendered by:
-��� has
Prin ign (Reprerntative) Municipality/Organization Date
Petitions receivedG
.: A L
Print/Sign (Elections Staff) Date
DATE STAMP:
11i3WI2Ivd2o SNOUT
69 :Zi Wd ZZ 83.E 1309
*Provide a completed copy to the Registration Manager*