Appointment of Treasurer_Julie Mitchell_11/8/2023 APPOINTMENT OF CAMPAIGN TREASURER RECEIVE®
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES NOV - 8 2Q23
(Section 106.021(1), F.S.)
VILLAGE CLERKS OFFICE
(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: Firs Middle, Last) 3. Address (include post office box or street, city, state,
zip code)
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4. Telephone . Candidate's Voter Registration #: /
oe
�5 (Not required for Qualifying Purposes)
a �
(Not required for Qualifying Purposes)-Phonetic spelling for audio ballot: Print name phonetically on the line below as you wish it to be pronounced on
the audio ballot as may be used by persons with di ilities(see i s uctions on page 2 of this form):
6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
/ J applicable:
V /I� ! �� '� I ❑ My intent is to run as a Write-In candidate.
8. If a candid9te fora partisan office, check block and fill in name of party as applicable: My intent is to run as a
I Write-In ❑ No Party Affiliation ❑ Party candidate.
9. 1 have appointed the following person to act as my Q Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy TreasureF 11. Telephone
Xa L.,/ fi'kx 6 1 5,� qk qA
12. iling dress 13 14rr 15. Z' d�e,/&
/& (JeAcc- I
16. 1 have designated the following bank as my LVJPrimary Depository ❑ Secondary Depository
17. Name of__Bank 0 18.Address
,S. '56A
19. Cit / —[2FP Co,unty 21. St 22. Zip Code
m,SL � )
UNDER ENALTIES 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.
23. Date 24. Signature of Candidate
T3 0 S X
25. l Treasurer's Ac eptance of Appointment(fill in e blanks and check the appropriate block)
1, �� �,y�`� ) do hereby accept the appointment
(Please Print or Type Name)
,ignated above as: Campaign Treasurer. Depu Treasur
UL7X )3 X �*
Date Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev.07/23) Rule 1S-2.0001, F.A.C.
APPOINTMENT OF CAMPAIGN TREASURER RECEIVED
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES NOV - 6 2023 JV
(Section 106.021(1), F.S.)
VILLAGE CLERKS OFFICE
(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 or street, city, state,
zip code)
4. Telephone 5. Candidate's Voter Registration#:
5 a qW (Not required for Qualifying Purposes) lef
(Not required for Qualifying Purposes)-Phonetic spelling for audio ballot: Print name phonetically on the line below as you wish it to be pronounced on
the audio ballot as maybe used b per ns with disa I'ies(see instru ions on age 2 of this form):
-1 - 66 - L - � � M- I • Cff • c�I �...
6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
/'► � applicable:
( nv ecLf ❑ My intent is to run as a Write-In candidate.
� W C.LJ�-1
e*N a candfgate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a
I Write-In ❑ No Party Affiliation ❑ Parry candidate.
9. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy re sur r 11. Telephone
1 ( ,50/ ) Rya q6 y
12. Mailing Address C�r1(f 13. city 1� 1 �to 15Si�qde�
16. I have designated the following bank as my Primary Depository ❑ Secondary Depository
17. Name of Bank 18.Address
��/l a us
-
19. Cit 20. ounty 7 2' 22. Code/
UNDEFOENALTIES 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.
23. Date 24. Si atur of Candi tp
At7*-U X
25. Treasur is A ceptance of Appointment(fill i the blanks and check the appropriate block)
I MI , do hereby accept the appointment
(Please Print or Type Name)
,ignated above as: Campaign Treasurer. ❑ Deputy Treasurer.
aL 1� X (I'L -W,
Date Signature of Campaign Treasurer or Deputy Treasurer
,,...... Rule 1S-2.0001. F.A.C.
OFFICE USE ONLY
STATEMENT OF
CANDIDATE RECEIVED
(Section 106.023, F.S.) NOV - 6 2023
(Please print or type) VILLAGE CLERKS OFFICE
candidate for the office of I ;
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
X
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)