HomeMy WebLinkAboutDocumentation_Miscellaneous_Tab 02_03/15/2016 APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRlNT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before o enin the cam ai n account. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
❑ Initial Filing of Form Re-filing to Change: �] Treasurer/Deputy � Depository � Office Q 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:
� My intent is to run as a Write-In candidate.
8. If a candidate for a artisan office, check block and fill in name of party as applicable: My intent is to run as a
�] Write-In � No Party Affiliation C0 Party candidate.
I have appointed the following person to act as my � Campaign Treasurer � Deputy Treasurer
10. 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. I have designated the following bank as my � Primary Depository � Secondary Depository
19. Name of Bank 20. Address
21. City 22. County 23. State 24. Zip Code
UNDER PENALTIES OF PERJURY,1 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
X
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
� , do hereby accept the appointment
(Please Print or Type Name)
designated above as: � Campaign Treasurer � Deputy Treasurer.
X
Date Signature of Campaign Treasurer or Deputy Treasurer
nc+ nr n in_.. wn�wn� Ridn ac_� nnn� � A!`