Acknowledgement of electronic receipt CastellanosMiami Shores Village
Application and Acknowledgement of Electronic
Filing Information
1. CHECK APPROPRIATE BOX(ES)
16 Candidate Measurer/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)
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4. Telephone
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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 littps:,'r'miamislioresviilrigetl.easyyotecaiispaigufinance.cam/ (the "System").
Credentials to log into the System are approved on an individual basis and 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 bled before midnight at the end of 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 internet access necessary to access the System, and problems with an individual
candidate's internet 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 ELECTRON FILING INFORMATION AND THAT
THE FACTS STATED IN IT ARE - .
6. Date
7. Signature Candidate/Committee Chair
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8. Treasurer's Application and Acknowledgement of El t c Filing Information (fill in the blanks and check
the appropriate block)
cknowledge that I am representing
I, �1✓J��C� _ (printed name), herewe,uty
the Candidate/Committee above as the Campaign Treasurer Treasurer
Date Si nature of Treasurer or Deputy Treasurer
00293211