DSDE-9 Burch 101-27-23A 10 :43 RC VD
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
21 Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy Depository Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip
George E. Burch code)
4. Telephone 5. E-mail address 1440 NE 101st Street
(305 ) 343-2738 georgeburchdvm@gmail.com Miami Shores FL 33138
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
applicable:
Miami Shores Village Council My intent is to run as a Write -In candidate.
8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a
❑ Write -In No Party Affiliation ® Party candidate.
9. 1 have appointed the following person to act as my Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
George C. Burch
11. Mailing Address 12. Telephone
1440 NE 101 st Street ( 305 ) 343-2738
13. City 14. County 15. State 16. Zip Code 17. E-mail address
Miami Shores Miami -Dade Florida 33138 georgeburchdvm@gmail.com
18. 1 have designated the following bank as my ❑ Primary Depository Secondary Depository
19. Name of Bank 20. Address
City National Bank 300 71 st Street
21. City 22. County 23. State
Miami Beach Miami -Dade Florida
24. Zip Code
33138
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
25. Date 26. Signature of Candidate
I - D-:-1 - 2-3 X 7Z. �� a LL)�
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
George E. Burch , do hereby accept the appointment
(Please Print or Type Name)
designated above as. 0 Campaign Treasurer Deputy Treasur
X�
Date
Signature of Campaign Treasurer or Deputy Treasurer
Rule 1S-2.0001, F.A.C.
DS-DE 9 (Rev. 10/10)