Jones- DSDE 9- Treasurer- Deborah A. Eisert 5-23-17DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.
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Received
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
MAY 2 3 2017
(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. ECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party
2. N sof an trials (in this order: First, Middle, Last)
3. Address (include post office box or street, city, state, zip
code) 5—IF 1 / L,9Tej-
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4.Telep one
5. E-mail address
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6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
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applicable:
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
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❑ Write -In [ No Party Affiliation ❑ Party candidate.
9.1have_appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer
10. Name ofT surer or Deputy Treasur,
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11. Mailing Address
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12, Telephone
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150 GrI�� �Ju�rs�nvi
13. ,zy
14. ty
15. ate
16. Zip Code
17. II addres r
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18. 1 have designated the following bank as my Primary Depository ❑ Secondary Depository
19. Na a of Bank
20. Address
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21.t2 my
237. 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 a of Can
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27. reasurer's Acceptc of Appointment (fill in the blanks hec a appropriate block)
an
I, do hereby accept the appointment
(Pleas rint or Type Name)
designated above as: Campaign Treasurer ❑ Deputy Treasurer.
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Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.
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