Glasser -DSDE9- Treasurer- D. Glasser 3-1-17APPOINTMENT OF CAMPAIGN TREASURER
Received
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES MAR 1 2017
Section 106.021(1), F.S.)
PLEASE PRINT OR TYPE) Office of City a-rk
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
42 Initial Filing of Form Re-filing to Change: 9 Tr asurer/Deputy 0 Depository Office Party
2. Name of Candidate(inthis(order. First, Middle, Last) 3. Address (include post office box or street, city, state, zip
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pc, , 30x 33LDSi0
4. Telephone 5. E-mail address
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322 2 2
t' lel )1412-(026251 osse re@ conrcc54:.ne+- /'"((
04I(- ,& J22l 3 3
6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office,check if
II (73
app
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L applicable:
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 9 No Party Affiliation Party candidate.
9 I have appointed the following person to act as my 0 Campaign Treasurer 9 Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
QGa;s1G(G55e(-
11. Mailing Address 12. Telephone
P . o ?) 330cto qQA )30(0
1)1. City 1 q.County 15. State 16. Zip Code 17. E-m it address
I64( (Bead Pk I FL 32233 of j FSS?rgrow,c<sk .ncl-
18. I have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank 20. Address
Nc y ciercl Credc,.l- Un', 3 9(01 47}I6„-t,c
21. City 22. County 23. State 24.Zip Code
AO6 4C beGGL, Otic t 32233
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.
DateX
S75atu
f dat
3I' '(-7
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I, (2 `5
Y GI L ass e.7- do hereby accept the appointment
Please Print or Type Name)
designated above as: 0 Campaign Treasurer 9 Deputy Treasurer.
3 l / 17 X
Date Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev.10/10) Rule 15.2.0001, F.A.C.