Filing Documents OFFICE USE ONLY
STATEMENT OF
CANDIDATE
(Section 106.023, F.S.)
(Please Type)
t i3 iI y 1, �(� P I o S
1 D
candidate for the office of ivAY R �Jo �'� I !/1 1 ( � �Ce(,;f/
have received, read and understand the requirements of Chapter 106,
Florida Statutes.
D 0 17
Signature of Candidate / ate
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes)
I C :01 Ti 1
DS -DE 84 (Rev. 03/08) F U r J J 11J
H3 n9 '101N k08 JO AI!;
TY OF B Y TON BEACH
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN 1`\ PM �'
DEPOSITORY FOR CANDIDATES
(Section 106 021(1), F S )
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
offic before opening the campaign account. OFFICE USE ONLY
1. H ECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change [ Treasurer /Deputy 0 Depository 0 Office 0 Party
2 Name of Candidate (in this order (� First, Middle, Last) 3 Address (include post office box or street, city, state, zip
Dr Pi 4 tl ! a S S code) it W- ay
4 Telephone 5 E-mail addr s Q 13, Ft 33 4y-6763
(S(1). -Z3 l7n( PSL SO LtUE'.60 Al
6 Office sought (include district, circuit, group number) 7 If a candidate for a nonpartisan office, check if
applicable:
P .. � � yr" fl My intent is to run as a Write -In candidate
8 If a candidate for pa office, check block and fill in name of party as applicable: My intent is to run as a
0 Write -In No Party Affiliation El Party candidate
9 I have appointed the following person to act as my 0 Campaign Treasurer El Deputy Treasurer
10 Name of Treasurer or Deputy Treasurer
D v Pt 0 tr- fe,a44
11 Mailing Address 12 Telephone
1G W_ TeL vct j 8e 33q — 67 6 3 ( .S - 6/ )s2_3 /701
13 City b8 14 C,pui 15 Late 16 Zip Code 17. E -mail addre
(►�' ss
, 33X36 P6LISSWL /1/F.
18 I have designated the following bank as my [] Primary Depository 0 Secondary Depository
19 Name f nk 20 Addres
i u. c, , 'V; (clam,/ AIlaPt (t( D-.2 iral
21 City 22. Cou ty B 23 State 24 ZI Code
Id 1v � Ft
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 STATED IN IT ARE TRUE.
25 Date 26 Signature of Candidate
K,! 7 x Dr Pi n fig- Btam
27 Treasurer's Acce tance of poi tment (fill in the blanks and check the appropriate block)
, J
I, r P(0 r , do hereby accept the appointment
Y P PP
(Please Tint or Type Name)
designated above as Campaign Treasurer p Deputy Treasurer
2 ( x Dr R'd- PteA4
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C.
-
i
S
Q U
W
m
2
O
F
Z
O
cc
cc
0
O
m
W
Q Y
Q J
8
a
O
a
0,
m