Hall- Affidavit of Financial Hardship- 6-22-17Received
AFFIDAVIT OF FINANCIAL HARDSHIP
(Section 99.093(2), Florida Statutes) I JUN 2 2 2017
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I, 1 M ,1 --- /IV >{rIK L . a candidate forfljMfffc,'@'&lerk
a (Zn Print Name t -/J
�_l c' —L. do hereby certify, pursuant
to Section 99.093(2), Florida Statutes, that I am unable to pay the 1% election assessment of
$ to qualify for nomination or election to public office because paying the
assessment would be an undue burden on my personal financial resources or on the financial
resources available tome. Under penalty of perjury, I declare that I have read the foregoing and
that it is a true and correct statement.
Date Signature of Candidate kAt. tstm�r L4uo�
State: ` Zip: �22
Sworn to (or affirmed) and subscribed before me this day of
,20 by
Received by:
Signature of Notary Public — State of Florida
Print, Type, or Stamp Commissioned Name of Notary
Public
Personally Known or Produced Identification_
Type ofldentification
Date of I
Remit within 30 days of close of qualifying to'.
Florida Elections Commission
107 West Gaines Street, Suite 224
Tallahassee, Florida 32399
Telephone: 850.922.4539 Fax: 850.921.0783
Jurat Certificate California only
A notary public or other officer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.
State of California
County of Los An L(e
Subscribed and sworn to (or affirmed) before me on this
dayof 7rNnC- 2011 by-- M, 1—F0(1 LA 1M[>n+ A-4 i(
proved to me on the basis of satisfactory evidence to be the person!/ who appeared before me.
Place Seal Here Signature Tr
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20
ROBERT A. MEDNKM
COMM. #2167991
NOTARY PLOW-GIYON
IAB ANGIRM COIINfY
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Description of Attached Document
Type or Title of Document I I
tiff -d n✓r� O F i�.�wnG a l �{9f®' S�,f
Document Date
I �o(ZI�I
Signers) Other Than Named Above
Ixmrna.avm
Number of Pages
1 Une
Received
JUN 2 2 2011
Office of City Clerk