Petition Drop Off ReceiptM1�=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)
I C" `mil \j i S _ has surrendered to Miami -Dade Elections Department
Name of Representative
`1 0
Quantity reported
Petitions for
Candidate nitiative
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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Phone # Email Mailing Address
Petitions surrendered by: (Governm711,al 1
Print Name
cy or Committee Staff)
Sicthature
Received by: (Miami -Dade Elections Department
� r
Print Name
DATE STAMP:
re
3-3 -Z3
Date
Date
`Provide a completed, copy to Registration Manager*
OFFICIAL RECEIPTNo.
MIAMI•
�MIAMI-DADS COUNTY-FLORIDA - 8053565
�D.Z.
RECEIVED FROM L! r�� li7 DATE v / ✓ / ��" �J
MONTH DAY YEAR
ADDRESS I ��/� G �� L� CASH
STREET ADDRESS
lG��j-%J f•1 ��J el-- CHECKS $
CITY STATE ZIP %
AMOUNT OF: �" " ��� DOLLARS, AND CENTS TOTAL $ /
1 , % FOR PAYMENT OF:
THIS RECEIPT NOT VALID UNLESS DATED, CUM LETED AND SIGNED BY RIZED EMPL E Of DEPARTMENT.
DEPT.. � 9-�'�/r BY: �
FOR OFFICE USE ONLY
SUBSIDIARY INDEX CODE