Harding, Mitchell-Treasurer Appt. M. Harding 2-22-13APPOINTMENT 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.
Received
r ;' X013
Office of City Clerk
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES): A,� �,,� j�
IN Initial Filing of Form Re -filing to Change/"`Treasurer/Deputy Itl Depository ❑ Office ❑ Party
2.Name of Cand/ idate (in this order: First, Middle,
1-0\e, I�lI �► i
Last)
, i(l
3. Address (include post office box or
code)/ f
street, city, state, zip
4. Telephone
1 I) '35)- CoolQ9
5. 9 -mail address
B i c po s5a � '1 ` I
lO 35
A Istn
0Si ✓ e Srree
each_
( j<2.23
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
Li T l/ e 0(111N11 53) Io,i e r ecJ J
applicable:
❑ 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 No Party Affiliation ® Party candidate.
9. I have appointed the following person to act as my jz Campaign Treasurer ❑ Deputy Treasurer
10. Name
of Tref surer
or Deputy Treasurer
11. Mailing Address
(G, 35 ) 1(11tr 0 e ;-re
12. Telephone
(70) 350 -664) `/
13.
City14.
ter,e IL
County
,A uQ (
15. State
I .
16. Zip Code
5,)2a
17. E-ma'l
address
. 3
_, A-
_Joni►`L
1 8 .Primary Depository
18. I have designated the following bank as my X
Secondary Depos •ry
19. Name ofank
---S-Psi(
��ei 0, Ile ZAK"(
20. Address
5 to v i4-1 la, 6Ivoi
21. City i
ay -610Q a.ei
2? --„County
` 0,0)a,f
23. State
Vivi ,DP�
24. Zip Code
30%2 6 69
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIG ' ASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
25. Date
re , 02c, 4()/3X
26. Signal re of Candidate
i< ►V 0------,
27. Treasurer's Acceptance of ppointment (fill in the blanks an• check the appropriate block)
61'1 C t k I , Ail it t`V1 do hereby ac - -appointment
(Please Print or Typ�ame)
designated above as: pi Campaign Treasurer El Deputy Treasurer.
f i • (c c5 l 3 X
date i ature of ampaign Treasurer or Deputy Tre-surer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.