Petition ReceiptOFFICIAL RECEIPT 7 No• 8 0 5 3 5 6 6
MIMIAM MIAMI-DADE COUNTY-FLORIDA
RECEIVED FROM `�� �F� DATE / r
MONTH DAY YEAR
ADDRESS ri/'f�J�Gi �_ CASH $
STREET ADDRESS
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CITY STATE ZIP
AMOUNT OF: DOLLARS, AND �`� CENTS TOTAL $ L
FOR PAYMENT OF:
THIS RECEIPT NOT VALID UNLESS DATED, COMPLE(ED AND SIGNED BY
DEPT.: BY:
FOR OFFICE USE ONLY
IZED EMPLOYMOF I)EPARTMENT.
SUBSIDIARY
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M I� �Il�DE
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)
I c)ny G- 17Av1
has surrendered to Miami -Dade Elections Department
Name of Representative
S) J-ess� va l i Vqsle-
Petitions for
Quantity
reported
Candidate/in itVative
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:
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av�5 -72Ica n c� c i s rn o rq
Phone
# Email J Mailing Address
Petitions' surrendered by: (Govern
Print Name
cy or
Sitihature
Received' by: (Miami -Dade Elections Department Sta
Print Name Signa,
DATE STAMP:
ZZ .0 Wd C- UW SH?
�I_j
Staff)
*Provid°e "a cvmpleted``capya Reg s . ..a .F.....
Date
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Date