Norris- Statement of Candidate- 3-22-17OFFICE USE ONLY
STATEMENT OF Received
CANDIDATE
(Section 106.023, F.S.) MAO 2 2 2017
(Please print or type)
y� Office of City Clerk
candidate for the office of Cca mtcSLclnoq Seal S
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
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Si nat re o C ndidate Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS -DE 84 (05111)