Candidate Packet_Basil Dalack_12/6/2017 OFFICE USE ONLY
STATEMENT OF RECEIVED
CANDIDATE
(Section 106.023, F.S.) DEC - 6 2017
(Please print or type)
VILLAGE CLERKS OFFICE
A*
12,
candidate for the office of
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
-7
Signature of Candidate Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS-DE 84(05111)