Norris -DSDE9- Deputy Treasurer- Brittany Norris 3-21-17DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.
Received
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
MAR 2 1 2017
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
Office of City Clerk
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
1. ,HECK APPROPRIATE BOX(ES):
14o�f Initial Filing of Form Re-fling to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last)
3. Address (include post office box or street, city, state, zip
code)
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4. Telephone
5. E-mail address
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cl1 ,CGNV\
6. Office sought (include district, circuit, group number)
T If a candidate for a nonpartisan office, check if
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applicable:
❑ M
M intent is to run as aWrite-In candidate.
8. If a candidate for aap rtisan office, check block and fill in name of party as applicable: My intent is to run as a
❑ Write-In ❑ No Party Affiliation [I Party candidate.
9.1 have appointed the following person to act as my ❑ Campaign Treasurer PW Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
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11. Mailing Address
12. Telephone
13, City
14. County
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15. State
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16. Zip Code
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17. E-mail address
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18. 1 have designated the following bank as my Ig Primary Depository ❑ Secondary Depository
19. Name of Bank
20. Address
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21. City//.�
22. County
23. State
24. Zip Code
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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. Si ure of Candate
X
27. Treasurer's Acceptance of Appointment fill"e e blanks and che(c}}} 'he 'ropriate block)
I, `(% 1T�V1llj I Y(/' k t, d6Tlereby accept the appointment
(Please Print or Type Name)
designated above as: ❑ Campaign TreasurerDeputy Treasurer.
3J1 a/2o�� X
Date at f Ca aign TrIs6surer or D uty asurer
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.