Glasser -DSDE9- Deputy Treasurer- Glasser 3-1-17Received
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES MAR 2017
Section 106.021(1), F.S.)
PLEASE PRINT OR TYPE) Office of CVy
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 Depository Office Party
2. Namerof Candidate(in this order: First, Middle, Last) 3. Address(include post office box or street, city, state,zip
e( ((n /'/`i s5e r
code) e, jgx 33 51
4.Telephone
l7"l
5. E-mail address c &O C/ FL 322 35
q"9 )412-Gz&2_ ,OlaSSere@cowaS+.
6. Office sought(include district, circuit, group number) 7. R a candidate for a nonpartisan office,check if
applicable:
f 1 ICyO,-- I SC/u'- ( 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. 1 have appointed the following person to act as my Campaign Treasurer ® Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
EI len I USse
11. Mailing Address 12. Telephone
P, a , 6q" 35os- o Flo`( ) 412 -G2GZ
13. City 14. County 15. State 16. Zip Code 17. E-mail addres,
k1IG IiLBead, DGivcl EL 32233 jI65serc
18. I have designated the following bank as my 15 Primary Depository D Secondary Depository
19. Name of Bank 20.Address
ull(
Bank_
Creel .4- Un,or gG ( /kklan olvd,
21. City 22. County 23. tate 24. Zip Code
bea l-,Di/74. ( L 32235
UNDER PENALTIES OF PERJURY.I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATOR OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
25. Date
I 1 X
Signatureaof `dat
1 /7.
27. Treasurer's Acce ptance of Appointment(fill in the blanks and check the appropriate block)
I^ P do hereby accept the appointment
Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
I) X c"
5/(
Date Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9(Rev.10/10) Rule 15-2.0001, F.A.C.