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PETITION SUBMITTANCE FORM" 13 liM °' 00
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Name on Petition (Candidate/Initiative) Vyyk.4te \WI e ti
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Office Candidate is seeking (if applicable): ( omcs _ r DItct'-- (-1
Number of Petitions Submitted: l Lei— Number SOE Counted:
Name of person submitting petitions: \e" �Th
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Address: In
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City, State, Zip Code:
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Phone t —7 a .0. ' Email:
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Signatur-. t.11101
� 411 --
�--- Date: fJ//, ,V;'" c
OFFICE USE ONLY
AP\-,Deputy's Initials: ,
Paid By Check: I0 1 7 C\4 O II
Paid By Cash: Receipt#: 1(60g
OR Undue Burden (verified)
BATCH #:
Revised March 2025
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0 4301 Cherry Road,West Palm Beach, FL 33409 0 561.656.6200 :,Q'R VotePalmBeach.gov 0 info@VotePalmBeach.gov
DATE l l )3 ias #041668
RECEIVED FROM /�
ADDRESS ', . II CQ Autikue ,. ;l u(L 1 3
AMOUNT
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' 1� `01"*.4 PALM BEACH COUNTY
DOLLAR$ �Q'' •o SUPERVISOR OF ELECTIONS
// ,t �j 4301 CHERRY ROAD
p CASH q�CHECK# tv ��;E� WEST PALM BEACH,FL 33409
0 MONEY ORDER 7DRAFT 4I,.,, TELEPHONE:561-656-6200
,0�„�+ WEBSITE www.votepalmbeaCI gov
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