Hill, James- Treasurer Appt. 3-4-13APPOINTMENT 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
MAR - 4 2013
Office of City Clerk
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
g Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
T_
in es Ke.Lw ti-��61\��
3. Address (include post office box or street, city, state, zip
code) 3-I2_ 7.41 5 -6, --pct
6-��a-vLti c 6 Cckc-C'I
cc oo
Tel hone
X9 _ac -le --A
(aa Q�5
9 o�-( ) aLt � 1513
5. E-mail address
bo o.A 1-A rn eA Cid 4cc,
6. Office sought (include district, circuit, group number)
e_DIM+Mi SS'tay- f - 5e0.& y
7. If a candidate for a non • artisan office, check if
applicable:
E My intent is to run as a Write -In candidate.
8. If a candidate for a p rtisan 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 my21/Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
f
LI
�' CO
11. Mailing Address
„stie ';mff ••ve a s KJt40 ;j (sti SG1eiV-1 ,
Yl)e--
12. Telephone
(904 )2.4 ^ . ;
13. City
/ -i-la l -k c 6ectcli
14. ounty
w/ri
15. State
�-
16. Zip Code
32.33
17. E-mail address
I; salvetiir01dG be lsbu+1i,nEt
18. I have designated the following bank as my Primary Depository ❑ Secondary Depository
19. Name of Bank
Re io s
20. Address
I I5 3rd - )ec-f-u0ebead\
21. City
I•12-0 -v ine�c t-�
22. County
L.� v oul
,'
23. State
I=1_--
24. Zip Code
522_53
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
`3 -LI - \ 3
26. Sign_ - of Cand • - -Ai
X / ii%i
27. Treasurer's Acceptance of Appointment (fill in blanks and check the appropriate block)
LCA/i% ,:. � ti-��j���;tf e,�: %0 LI sift �v�1% do hereby accept the appointment
_ Q
designated above
-4
(Please Print or Type Name)
as: Campaign Treasurer ❑
- 13 X - \U.
De.0 Treasurer.
s.
Date Signatu - o Campaign Treasurer o Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.