Glasser -DSDE9- Change of Depository- DepTreas- D.Glasser 3-2-17Received
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES MAR 2 2017
Section 106.021(1), F.S.)
PLEASE PRINT OR TYPE) Office of City Clerk
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: Trr asurer/Deputy 0 Depository Office Party
2. Name of Candidate(in this order: First, Middle, Last) 3. Address(include post office box or street, city, state,zip
eir G16s5 °r
ode)
p. o . box 33 ) 5to
4. Telephone 5. E-mail address i
oy ) 412 62 b2 Jtc 5er fi
ti141 6e< r L 3Z- e33
e@C cG . ,,e
6. Office sought(include dieirict, circuit, group number) 7. if a candidate for a nonpartisan office,check If
applicable:
Mel 5 e<K I My intent is to run as a Write-In candidate.
8. If a candidate for a partisan office, check block and fill In name of party as applicable: My intent is to run as a
Write-In 0 No Party Affiliation 0 Party candidate.
9. I have appointed the following person to act as my [T Campaign Treasurer fl Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
11. Mailing AddreS 12. Telephone
C3r 3305 0 M ) 3Ko - S-71fr"
13. City 14. County 15. State 16. Zip Code 1T. E-mail addressD41 \:`- c DI4( 1 1-7L 32233p1 I5se(@Ca,r-C4S-F. eH
IS. I have designated the following bank as my prPrimaryDepository Secondary Depository
19. Name of Bank 20. Address
weR Vary 031 Pcm ,-1,L 6Iue,
21. City 22. Co ty 23. State 24.Zip Code
e 1- &a AucI 2)233
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 f Candidate
3/I l I x
27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block)
I, Da: s 3 (a Lass er do hereby accept the appointment
Please Print or Type Name)
designated above as: IA Campaign Treasurer 0 Deputy Treasurer.
3 /1 / / -9- x 0i2e -
Date Signature o?Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.