Hall -DSDE9- Treasurer- M. Hall 5-17-17DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.
Received
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
MAY 17 2017
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
Once of City Cleric
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
1. C CK APPROPRIATE BOX(ES):
Initial Filing of Form Re -Fling to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. �N� e of Candi/date (in this order: First, Middle, Last)
L_76 Y LAW,
3. Address (inclu a post office box o street, city, state, zip
code) rlo�^ �2G2�-�/�dK Lam✓
/
C �L ����
4. Telephone
5. E-mail address%V-'�)
('?A )
i'mN"s "9 I .
6. Office solig�it (include district, circuit, group nuti
�O �i
y
7. If a candidate for a nonpartisan office, check if
applicable:
-I o I L '✓'�' ' —� C
C OF
❑ My intent is to run as a Write -In candidate.
8. If a candidate for a 22i office, check block and fill in name of parry as applicable: My intent is to run as a
E] Write -In ZNo Party Affiliation ❑ Party candidate.
--9, l haaeappointed the following person to act as my Campaign Treasurer El Deputy Treasurer
or Deputy Tre
10. Name of T easurerZ`
surer
j
IN
U
11. Mailing 4ddress / �
&165 qL � D BC 63223
12. Telephone
('")s 13
13, City14
TTJ�7i1c IA_
County
SUVtIC
15. State
16. Code
17. E-mail ado`eiiii
18. 1 have designated the following my {]'Primary Depository Secondary Depository
�as
�,.bank
19. Name CC(5iank 1 �� / / I r )
L'
•J
1b2rIss14t ^TV- }SL -v>
21. City
22. County
23 §tate
24. Zip Code
IVIi"
v -H �
L k it
223 3
-UNDEPPENALTIES 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
re (� 1
XE±=
's Acceptance of Appointment(mil in the blanks and check the appropriate block)
27. Ii1I Treaassurrerr�+
t`
c`>v- JI ll�-l.��l`"'
I, 1IL , do hereby accept the appointment
(Please Prin r T pe Name)
"
designated a ove as: Campaign Trea e Treeif
x
117
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.