Petition Drop Off Receipt CastellanosM1�MMADE
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)
C.-' L %,, I has surrendered to Miami -Dade Elections Department
Name of Rcpresantativ�.
Petitions for \' " G s I C
Quantity reporter'
C c- c,4c, I I a r) to 5
Candidate/initiative
NOTE: Qu antity repo;YLd is not official until counted by Elections staff. You will be notified if the
official count does .not match quantity reported.
Provid�� he following for the Candidate or Initiative contact person in case we need additional
i)c=TJ
Phonf,
1 v rLG0 Ne-2nd a ✓tnve,
Email J Mailing Address
Petitions surrendered by: (Goven
Cam'
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ir�f innr;
Cy orx�ommittee Staff)
Rec,. d hy: (r✓liami-Dade Elections Department Staff)
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Date
Date
ovide a completed•�'opy to RegistratianF Nanag "'
M®�OFFICIAL RECEIPT ��G���'�8 No. 8053567
MIAMI-DADE COUNTY-FLORIDA'�, c�C(�
RECEIVED FROM/ S
ADDRES
. - ';; 0 STREET ADDRESS ff �
CITY STATE ZIP
AMOUNT OF: DOLLARS, AND (� CENTS
FOR PAYMENT OF:
DATE If1 D
MONTH tiAY YEAR
CASH
CHECKS $
TOTAL $ f
THIS RECEIPT NOT VALID NLESSDATED,, COMPLETED AND SIGNED BY Ali ORIZED DY� OF DEPARTMENT.
, ,,
FOR OFFICE USE ONLY
SUBSIDIARY INDEX CODE
107.01•1 6)aa