VIIi- Form DSDE86 Request for Return of Contribution
__________________________________
__________________________________
REQUEST FOR RETURN OF CONTRIBUTION
(Section 106.021, F.S.)
(PLEASE TYPE)
I, ________________________________________________________,
hereby request that the pro rata share of my contribution to the
campaign of _______________________________________ as a
candidate for the office of _____________________________________
be returned to me pursuant to Section 106.021(1)(a), Florida Statutes.
X__________________________________ _____________________
Signature Date
Street Address
City State Zip Code
DS-DE 86 (Rev. 09/95)