Keane - DSDE 9 - Appt. Treasurer- David Pazdernik 8-4-22APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN`
DEPOSITORY FOR CANDIDATES
A;J'�
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
BY.......
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NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
V3 Initial Filing of Form Re -filing 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
SineCZ+r-ic_ - KEG r\e_
code)
�q5 aa+or'l Go, t�r.
Ji1���Gn� �` Qc� 333
4. Telephone
5. E-mail address
(q�r ) 5.2I 37y3
seams . v,,- C g0 cvcr. co,h
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6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
/ .�&c4 �Afil.
appli❑cabley
M intent is to run as a Write -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 ❑ Party candidate.
9. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer
10. Name of Treasurer Deputy Treasurer
;
BVI r r)
11. Mailing Address
12. Telephone
(�3 o A JAJo r Su ,'te 1 - 3 1 7
(26 z ) -7 l ':�7
13. City
14. County
15. State
16. Zip Code
17. E-mail address
N1 t� � � okf, �e,1
S -t �.l A, f
FL-
�3? 672
Ae, v e. `i Z d f f,7 ;k � .� � . I ,Cor►,
18. 1 have designated the following bank as my [l Primary Depository ❑ Secondary Depository
19. Na of Bank
G n Y OF iii Vii'• `Ga
20. Address
30l 3�� �'�'
21. Cityint
r
22 ountyy
23. StLt
242. Z
C
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 S ATED IT,# TRUE.
25, Date
26. Signature a
Fye E*2L
11
,
27. Treasurer' Acceptance of Appointment (fill in the blanks and check the appropriate block)
Z n K
I, V I 1 I do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer ❑ Deputy T urer.
I t 2 `Z X
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.