Petition Drop Off Receipt WalshM IAM14DADE
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)
7�' &-, D)WQ I s __ . has surrendered to Miami -Dade Elections Department
Name of Representative
(R5 P= 4� 1nLa
Petitions for
Quantity reported
Candidate/initiative
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:
Phone #
Email
Petition s surrendered by: (GoN
Print Name
ental
l o c;ksp r��zr�o� a ✓.enV�
1Mtarnt 5-�3.3i.3[
Mailing Address T-
mittee Staff)
cP /Z
Date
Received by: (Miami -Dade Elections Department Staff)
7'� ��
M®mmOFFICIAL RECEIPT NO. 8 0 5 3 5 6 9
MIAMI-DADE COUNT —FLORIDA
RECEIVED FROM DATE 31
MONTH DAY YEAR
ADDRESS^ /OD c.('2*) �'� CASH $
STREET ADDRESS
CITY STATE
AMOUNT OF. DOLLARS, AND _
FOR PAYMENT OF:
THIS RECEIPTNOT VALID UN�S DATED, M LETED AND SIGNED/ BY A ,HORIZED EMPLOY OF DEPARTMENT.
DEPT.: r BY:
FOR OFFICE USE ONLY
CHECKS $
ZIP
CENTS TOTAL $
TRANS SUBSIDIARY INDEX CODE SUBOBJECT AMOUNT
iu�.vi i wv.
- ".1,