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74 TO F 4-11,110011
MO 1? r t v uny
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021 (1), F.S.)
(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'. C3 Treasurer/Deputy C3 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. E-mail address
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
applicable:
F� My intent is to run as a Write -In candidate.
8. If a candidate for a eartisan 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.
fl I have appointed the following person to act as my Campaign Treasurer Deputy Treasurer
j. Name of Treasurer or Deputy Treasurer
11. Mailing Address 12. Telephone
13. City 14. county 15. State 16. Zip Code 17. E-mail address
18. 1 have designated the following bank as my
19. Name of Bank
21. City
22. County
[:] Primary Depository
120. Address
23. State
[] Secondary Depository
24. Zip Code
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 26. Signature of Candidate
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
11 , do hereby accept the appointment
(Please Print or Type Name)
isignated above as: C] Deputy Treasurer.
Campaign Treasurer
X
Date
Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule IS -2.0001, F.A.C.
OFFICE USE ONLY
STATEMENT OF
CANDIDATE
(Section 106.023, F.S.)
(Please print or type)
candidate for the office of
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(l)(c), 106.265(l), Florida
Statutes).
DS -DE 84 (05/11)
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CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name (2) I.D. Number
(3) Cover Period through (4) Page of
(5) (7) (8) (9) (10) (12)
Date Full Name
(6) (Last, Suffix., First, Middle)
Sequence Street Address & Contributor Contribution In-kind
Number City, State, Zip_ Code lype Occupation Type Description Amendment Amount
DS -DE 13 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(2) I.D. Number
(21 Cinvpr Ppriod throuah 1 (4) Paae of
(5)
Date
(7)
Full Name
(Last, Suffix, First, Middle)
Street Address &
Citt, State, Zip Code
(8)
Contributor
lype Occupafton
(9)
Contribution
lype
(10)
In-kind
Description
(11)
Amendment
(12)
Amount
(6)
Sequence
Number
DS. -DE 13 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(2) I.D. Number
121 Cnvp-r Pprind throuah (4) Paue of
(5)
Date
(7)
Full Name
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
(8)
Contributor
Type Occupation
(9)
Contribution
_lype
(10)
In-kind
Description
Amendment
(12)
Amount
(6)
Sequence
Number
DS -DE 13 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(2) I.D. Number
(.11 Cnvp-r Parind throuah (41 Paae of
(5)
Date
(7)
Full Name
(Last, Suffix, First, Middle)
Street Address &
Ci!y, State, Zip Code
(8)
Contributor
ype_._l Occupation
Tjpe.
(9)
Contribution
___Iype
(10)
In-kind
Descriplion
Amendment
(12)
Amount
(6)
Sequence
Number
DS -DE 13 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name
(3) Cover Period throu-qh
(2) I.D. Number
(41 Paae of
(5)
Date
(7)
Full Name
(Last, Suffix, First, Middle)
Street Address &
C!!y, State, Zip_ Code
Contributor
lype Occupation
(9)
Contribution
Type
(10)
In-kind
Descrip Lion
Amendment
(12)
Amount
(6)
Sequence
Number
DS -DE 13 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Type candidate's full name or name of the political committee (PC), committee of continuous existence (CCE) or
party executive committee (PTY).
(2) Type the identification number assigned by the Division of Elections.
(3) Type cover period dates (e.g., 7/1/03 through 9/30/02). (See Calendar and Election Dates for appropriate year
and cover periods.)
(4) Type page numbers (e.g., 1 of 3 ).
(5) Type date contribution was RECEIVED (Month/DayNear).
(6) Sequence Number — Each detail line shall have a sequence number assigned to it. Sequence numbers are to be
assigned within each reporting period and for each type of detail line. Thus the report type, detail line type, and
sequence number will combine to uniquely identify a specific contribution, expenditure, distribution or fund transfer.
This method of unique identification is required for responding to requests from the Division and for reporting
amendments.
For example, a Q1 report having 75 contributions would use sequence numbers 1 through 75. The next report
(Q2), comprised of 40 contributions would use sequence numbers I through 40. Contributions on amended 01
reports would begin with sequence number 76 and on amended Q2 reports would begin with sequence number
41. See the Amendment Type instructions below.
(7) Type full name and address of contributor (including city, state and zip code).
(8) Enter the type of contributor using one of the following codes:
Individual
Business
= B (also includes corporations,, organizations, groups, etc.)
Committees
= C (includes PC's, CCE's and federal committees)
Political Parties
= P (includes federal, state ad county executive committees)
Other
= 0 (e.g., candidate surplus funds to party, etc.)
Type occupation of contributor for contributions over $100 only. (If a business, please indicate nature of
business.)
(9) Enter Contribution Type using one of the following codes:
NOTE: Cash includes cash and cashier's checks.
DESCRIPITION
CODE
Cash
CAS
Check
CHE
In-kind
INK
Interest
INT
Loan
LOA
Membership dues
DUE
Refund
REF
(10) Type the description of any in-kind contribution received.
Candidate's Only — If in-kind contribution is from a party executive committee and is allocable toward the
contribution limits, type an "A" in this box. If contribution is not allocable, type an "N".
(11) Amendment Type (required on amended reports) — To add a new (previously unreported) contribution for the
reporting period being amended, enter "ADD" in amendment type on a line with ALL of the required data.
The sequence number for contributions with amendment type "ADD" will start at one plus the number of
contributions in the original report. For example, amending an original Q1 report that had 75 contributions, means
the sequence number of the first contribution having amendment type "ADD" will be 76; the second "ADD"
contribution would be 77, etc. When amending an original Q2 report that had 40 contributions, the sixth "ADD 3Y
contribution would have sequence number 46.
To correct a previously submitted contribution use the following drop/add procedure. Enter "DEL" in amendment
type on a line with the sequence number of the contribution to be corrected. In combination with the report number
being amended, this sequence number will identify the contribution to be dropped from your active records. On
the next line enter "ADD" in amendment type and ALL of the required data with the necessary corrections thus
replacing the dropped data. Assign the sequence number as described above.
(12) Type amount of contribution received. Committees of continuous existence ONLY: Any contribution which
represents the payment of dues by a member in a fixed amount pursuant to the schedule on file with the Division
of Elections need only list the aggregate amount of such contribution, together with the number of members paying
such dues and the amount of membership dues.
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name
(2) I.D. Number
(3) Cover Period
through
(4) Page of
(5)
(7)
(8)
(9) (10) (11)
Date
Full Name
Purpose
. (6)
(Last, Suffix, First, Middle)
(add office sought if
Sequence
Street Address &
contribution to a
Expenditure
Type
Number
City,, State, Zip Code
candidate)
Amendment Amount
DS -DE 14 (Rev. 08103)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
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