Acknowledgement of electroninc filing Harris02-2.3-21 1 4:1:3 RC VD
Miami Shores Village
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Application and Acknowledgement of Electronic
Filing Information
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1. CHECK APPROPRIATE BOX(ES)
$ Candidate )2i Treasurer/Deputy ❑ Committee ❑ Committee Treasurer
2. Name of Candidate/Committee (First, Middle, Last)
3. Address (include P.O. box or street, Village, state,
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zip code)
4. Telephone
5. E-mail address
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Campaign finance activity may be filed with the Village Clerk using the electronic campaign finance reporting system available
online at https://mittst3ishoresvillageil.eaxyyolecatnnaignf siaiice.conil (the "System").
Credentials to log into the System may not be shared —even with member of the same campaign or committee. Each user who is
approved for credentials is responsible for protecting those credentials from disclosure or compromise. Once credentials have been
approved for a user, that user is deemed responsible for every report filed using. those credentials until such time as the Village
Clerk is notified of disclosure or compromise of those credentials. Campaign or committee must immediately notify the Village
Clerk if any user associated with that campaign or committee becomes ineligible to hold the credentials issued to that user.
Each report must be filed before midnight on the due date. Reports that have been filed late are subject to fines pursuant
to Florida Statutes sections 106.07(8) or 106.29(3), as applicable.
By filing a report through the System, a person (i) is deemed to have electronically signed the report under oath and to have certified
the correctness of the report in accordance with Florida Statutes sections 106.07(5) or 106.29(2), as applicable; (ii) is responsible
for the accuracy and veracity of the report; and (iii) commits a criminal act by certifying a report that is known to be incorrect,
false, or incomplete.
A report is deemed filed with the Village Clerk only when the System issues a receipt confirming the date and time at which the
report was filed. The system will issue a separate notice for the subsequent acceptance or rejection of the report by the Village
Clerk. Once a report has been filed with the Village Clerk, it may be changed only by filing an amendment to that report.
The Village is not responsible for providing the intemet access necessary to access the System, and problems with an individual
candidate's intemet access at a residence, office, coffee shop, etc. do not excuse late filing by that candidate. The Village Clerk
will provide an alternate filing deadline for candidates only in the event that the Reporting System is generally inoperable
and all candidates filing via electronic means are affected.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ AND UNDERSTAND THE FOREGOING
FORM FOR APPLICATION AND ACKNOWLEDGEMENT OF ELECTRONIC FILING INFORMATION AND THAT
THE FACTS STATED IN IT ARE TRUE.
6. Date
7. Sign re of Candidatl mmittee Chair
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8. Treasurer's Application and Acknowledgement of Electronic Filing Information (fill in the blanks and check
the appropriate block)
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I, Sarayr► rr-IS (printed nair, ), hereby acknowledge that I am representing
the Candidate/Committee above as the ❑ Campaign Tre rer ❑ eputy r asurer
A3/ at)I x -
Date - Signature of Treasurer or Deputy Treasurer
00293211