Daugherty, Jonathan Treasurer Appt. 1-25-13 APPOINTMENT OF CAMPAIGN TREASURER Received
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES JAN 2 5 2013
(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):
Zr Initial Filing of Form Re-filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office p Party
2. Name of Candidate(in t 's order: First, Middle, Last) 3. Address(include post office box or street, city, state,zip
im code)SUSi�� o /41Sc (5 S /.
4. Telephone 5. E-n42-ail address
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6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office,check if
applicable:
C l'"/_.i Cc>iy‘m ,s 5,0/k e E 5eck--/-5 0 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-Ino Party Affiliation ❑ Party candidate.
9. I have appointed the following person to act as myampaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or DeputyTreasurer
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11. Mailing Address / 12. Telephone
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13. City
I 14. CountyC� 15. State 16. Zip Code 17.) E-mail address
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18. I have designated the following bank as my ❑ Primary Depository ❑ Secondary Depository
19. Name of Bank / 0 20. Address L/ Z S / I /i/j'4/ �� �e( �S� � r�/ mit. r C
21. City P ge' 22. CountLA/ liA / 23. State/ 2431 Z ode
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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 26. Signature of Candidate
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27. Treasurer's Acceptance/ of A ointment(fill in the blanks and check the appropriate block)
I, vrG t-Ck_A iP-1'/ , do hereby accept the appointment
(Please Print or Type Nan)e)
designated above as: ❑ Campaign Treasurer ❑ Deputy Treasurer.
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Date Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C.