Appointment of Treasurer_Basil Dalack_12/6/2017 PPOINTMENT OF CAMPAIGN TREASURER RECEIVED
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES DEC - 6 2017 M
(Section 106.021(1), F.S.) q
VILLAGE CLERKS OFFICEW%
(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):
( 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
fty, tate i
code)
4. Telephone . E-mail address / Fti,
6. Office sought(include district, circuit, group num r) 7. If a candidate for a nonpartisan office, check if
applicable:
Sly My intent is to run as a Write-In candidate.
8. If a candidate fora 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.
have appointed the following person to act as my Campaign Treasurer Deputy Treasurer
i u. Name of Treasurer or=DTreasurer
11. Mailing Address 12. Telephone .
13. City 14. County 15. State 16. Zip Code 17. E-mail address
18. I have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank 20. Address
OF,�G S ����v
21. City j✓p 22. County 23. State 24. Zi Code
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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 j 26. Signature of Candi ate
,>-
27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block)
I, SIG -, " _ , do hereby accept the appointment
(P ease Print or Type Name)
;ignated above as: 0/ Campaign Treasurer � Deputy Treasurer.
/ X ,,.
Date Signature of Campaign reasurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.