HomeMy WebLinkAboutElliott, Robert DS-DE 9 & DS-DE 84 - 2024 07 18.pdfAPPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
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DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
JUL 18 ?024
(PLEASE PRINT OR TYPE)
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
NOTE: This form must be on file with the filing officer before
opening the campaign account.
OFFICE USE ONLY
I. C ECK APPROPRIATE BOX(ES):
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 PO Box or Street, City, State, Zip Code):
(Please Print or Type Name)
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4. Telephone:
5. Candidate's Voter Registration #:
6. Email Address:
(not required for qualifying purposes)
7. Office Sought (include district, circuit, group, or seat #):
8. If a candidate for a nonpartisan office, check the box
L/ T y Lr"�^'' `s`J v3 r-e r 1 S+C 1Q+ S 0 1 V�>
if applicable:
❑ I intend to run as a Write-in Candidate,
9. If a candidate for partisan office, check the box and fill in the name of the party as applicable: I intend to run as a
❑ Write -In Candidate. ❑ No Party Affiliation Candidate. ❑ Party candidate.
10. I have appointed the following person to act as my: ® Campaign Treasurer ❑ Deputy Treasurer
11. Name of Treasurer or Deputy Treasurer:
12. Telephone:
13. Email Address:
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w�n- �'�s�i.o��
14. Mailing Address:
City:
16. State:
17. Zip Code:
+1`5.
18. 1 have designated the following bank as my (check appropriate box): ❑ Primary Depository ❑ Secondary Depository
19. Name of Bank:
20. Address:
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1 / ,61 2; . S e hi 39
21. City:
22. County:
23. State:
24. Zip Code:
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UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR THE APPOINTMENT OF THE
CAMPAIGN TREASURER AND DESIGNATION OF THE CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
26. Signature of Candidate:
25. Date: `11)9
V
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate box)
1, 12�3 �,: r' lYl _ I , c- �- , ;- ,- do hereby accept the appointment designated above as:
(Please Print or Type Name)
0 Campaign Treasurer. ❑ Deputy Treasurer.
29. Signature of Campaign Treasurer or Deputy Treasurer
28. Date:
DS-DE 9 (Rev. 09/23) Rule 1S-2.0001, F.A.C.
STATEMENT OF
CANDIDATE
(Section 106.023, F.S.)
(Please print or type)
I, [�Nortrcr (I
LLIoY N
candidate for the office of
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
Signature of Candidate
Date
F.
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).
DS-DE 84 (OS/11)