Petition ReceiptMIAMI. ADE
Miami -Dade Elections Department
2700 NW 871" Avenue
Miami, Florida 33172
305-499-8363
Petition Drop -Off Receipt
(To be completed when receiving petitions from Governmental Agency or Committee)
n�? �' �� I s has surrendered to Miami -Dade Elections Department
Name of Representative
`S � ; 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
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Phone # Email J Mailing Address
Petitions surrendered by: (Gover e-ntalA90cy or ommittee Staff)
:�'rint Name t3i na a Date
Re-eived by: (Miami -Dade Elections Department Staff)
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Provide a completed'copy.jv` 7a9,
OFFICIAL RECEIPT
MIAMI-DADE COUNTY-FLORIDA
/ el'..' �
No. 8053568
COUNTY
AMOUNT ❑F:
FOR PAYMENT OF:
ol
RECEIVED FROM �`G G DATE `3 1�1
MONTH DAY YEAR
ADDRESS %I�QU�/ CASH $
STREET ADDRESS
�? �•� � . CHECKS $
CITY STATE ZIP
DOLLARS, AND CENTS TOTAL $
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THIS RECEIPT NOT W(61) ESS DATED, COMPETED AND SIGNED BY U RIZED EMP O O DEPARTMENT.
DEPT.: �!'�� Wad/ BY:
FOR OFFICE USE ONLY r
ARY
SUBSIDI
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