Daugherty, Jonathan Change to Depository Designation 3-29-13 Received
APPOINTMENT OF CAMPAIGN TREASURER MALI 2 0 2013
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
Office of City Clerk
(PLEASE PRINT OR TYPE)
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: ❑ Treasurer/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
I code)
JOnc.. // 0. G(✓,6) .80„, hf'r_�
4. Telephone I ne 5. E-mail addres3
( 7 L( ) 0 S l- z_c( cl jc)„u' 1,e r @ Co<_� , L'�
6. Office sought(include district, circuit, gr up number) 7. If a candidate for a nonpartisan office,check if
applicable:
[v / -4 C Urvk el SS iUyvt I $ vi 3 ❑ 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 2"---No Party Affiliation 0 Party candidate.
9. I have appointed the following person to act as my ❑/ Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer or Deputy Tre suurer I,�
o \cn G.� n Dc4 ,_) ” ec-i,_
11. Mailing Address 12. Telephone
g3o k;A ; cos Sf. ( ?Oy ) Y'Y'l - Z V67
13. City 14. ounty 15. State 16. Zip Code 17. E-mail address
/-1 -/ 1,.i-/< -'c,cl VvCk / /-- 322_ rael„, Lci ,Lig<<-,c,A . us
18. I have designated the following bank as my _ A-4 Primary Depository ❑ Secondary Depository
19. Name of Bank 120. Address --)
OA( io 0„ 9 '.AgAC<c,_ / 1 `7730 1/9/cA rst∎i∎ „ s 4.(---)/ .
21. Cit y 22. Cou t 23. State 24. Zip Code
_)Uc (CSonui /!e Uu '✓;, / 7_1 z S_
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 -_.
3 / /
z � / 3
X ,,
27. Treasurer's Accept ce of Appointment(fill in the blanks and check the appropriate block)
I, J ca l ,c, I G.��/t cc c__J c
/ er , do hereby accept the appointment
(Please Print orT�pe Nam
designated above as: Campaign Treasurer 0 Deputy Treasurer
73[2 6 %/ X /
Date Signature of'tampaign Treasurer or Deputy Treasurer
DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.