Keane - DSDE 9 - Appt. Deputy Treasurer- Rebecca Ciric 8-10-22t , 7T
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN �� I ��, J 0 -,p?
DEPOSITORY FOR CANDIDATES
(Section 106,021 (1), F.S.)
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(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: M 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
code) r,
4. Telephone
5. E-mail address
6. Office sought (include district, circuit, group number)
7. If a candidate for a nonpartisan office, check if
100yor
applicable:
E] 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
Write -In [] No Party Affiliation [_1 Party candidate.
9. 1 have appointed the following person to act as my Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Dep utyrrTreasurer
L � l�� L
11. Mailing Address
3 LI mss + ,, C�
12. Telephone
(,v ti) e 6 7-b 5 S�p
1 City
14. C un
15. S ate
16. Zip Code
17. E-mail address
5
V�
3 �SGi'
far
18. 1 have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank
72A zi L (22 A r,<< U/3
7�dressPf C,s�-
21. City
2Co my
23. Stat
24. Zip Code
22�
UNDER P ALTIES 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 RE TRUE.
25. Date
26. Signature of Candidate
2,e4,72X
��
27. Treasurer's� Acceptance of Appointment (fill in the blanks and check the appropriate block)
do hereby accept the appointment
(Please Pnnt or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10110) Rule 1S-2.0001, F.A.C.