Hock-DiPolito, Doreen - Seat 2CAMPAIGN TREASURER'S REPORT
(1) Doreen DiPolito
SUMMARY
!EMMY
FEB 1 6 2011
OFFICIAL RECORDS AND
LEGISLATIVE SRVCS DEPT
Name
(2) 420 Druid Road West
Address (number and street)
Clearwater, FL 33756
City, State, Zip Code
❑ Check here if address has changed
(4) Check appropriate box(es):
(3)
City
ID Number:
Council, Seat 2
✓ Candidate Office Sought: City of Clearwater
• Political Committee (PC)
❑ Check
here if PC or ECO has disbanded
here if PTY has disbanded
tf no other IE or EC reports will be filed
❑ Electioneering Communications Org. (ECO)
• Party Executive Committee (PTY) • Check
❑ Independent Expenditure (IE) (also covers an
individual making electioneering communications)
• Check here
(5) Report
Cover Period: From 11 / 01 / 2015 To
Identifiers
12
Election
17 / 2015 Report Type: TR
IJ Original ■ Amendment ❑ Special
Report
(6) Contributions This Report
Cash & Checks $ , 150. 00
(7) Expenditures
Monetary
Expenditures
Transfers
Office Account
Total Monetary
This Report
$ 5 , 925 00
Loans $
to
$
Total Monetary $ 150. 00
$ 5 925 00
In -Kind $ , ,
(8) Other
$
Distributions
.
(9) TOTAL Monetary Contributions To Date
$ , 5 , 925 . 00
(10) TOTAL
$
Monetary Expenditures To Date
, 5 , 925 . 00
(11) Certification
It is a first degree misdemeanor for any person
I certify that 1 have examined this report and it is true, correct,
(Type name) Thomas M. Kiernan
to falsify a public record (ss. 839.13, F.S.)
and complete:
(T . _ :.. _) Doreen DiPolito
❑ Individual (only for IE o Treasurer ❑ Deputy Treasurer
0 Candidate
X
! a only for PC and PTY)
or electioneering comm.)
2sa� t ,"'a , `. 1 to `* `
� =
Signature
Signature
- ut71uoev.
SEE REVERSE FOR INSTRUCTIONS
CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS
Doreen DiPolito
(1) Name
(2) I.D. Number
11 01 2015 12 17 2015 1
(3) Cover Period / / through / / (4) Page of
r
(5)
Date
(7)
Full Name
-
Contributor
Type
(8)
Occupation
(9)
Contribution
Type
(10)
In -kind
Description
(11)
Amendment
(12)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
11
/
01
/
15
Kara Behar
990 Bay Esplanade
l
Business Dir
0
Che
$150.00
01
Clearwater, FL 33767
/
/
/
/
/
/
/
/
/
/
L.
/
/
DS -DE 13 (Rev. 11113)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT — ITEMIZED EXPENDITURES
(1) Name Doreen DiPolito (2) ID. Number
(3) Cover Period 11 / 01 / 2015 through
12 / 17 / 2015
(4) Page 1
5
(8)
Date
(7)
Full Name
(8)
Purpose
(add office sought If
contribution to a
candidate)
(9)
Expenditure
Type
(10)
Amendment
(11)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
11 /04 / 15
Jeremiah Khokhar Photography
111B
Knollwood Dr
Photography
Safety Harbor, FL 34695
Mon
$950.00
01
11 04 15
I /
Gulf Coast imprinting
2050 Tall Pines Dr Ste A
Printing
Largo, FL 33771
Mon
$243.21
02
11 04/ 15
Turner Printing Company, Inc.
/
829 Belleair Rd
Stamp
Clearwater, FL 33756
Mon
$21.77
03
1
11 17 15
/ /
City of Clearwater
112 S Osceola Ave
Filing & Election
Assessment Fees
Mon
$310.42
Clearwater, FL 33756
04
11 18/ 15
Thomas Kiernan
/
569 71st Ave N
St Petersburg, FL 33702
Treasurer Services
Mon
$500.00
05
12 12 _ 15
City of Clearwater
/ //
112 S Osceola Ave
Petition Signature
Clearwater, FL 33756
Verification
Mon
$28.10
06
12 17/ 15
Elias Anastasopoulos
/
1600 Gulf Blvd
Pro -rata
Clearwater, FL 33767
Contribution Refund
Dis
$163.35
07
12 17/ 15
Ed Armstrong
/
1614 Santa Barbara Dr
Pro -rata
Dunedin, FL 34698
Contribution Refund
Dis
$65.34
08
DS -DE 14 (Rev. 11113)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name Doreen DiPolito (2) I.D. Number
(3) Cover Period 11 / 01 /2015 through 12 / 1Y 7 /2015
(4) Page 3 of. 5
(3)
Date
(7)
Full Name
(8)
Purpose
(add office sought If
contribution to a
candidate)
(9)
Expenditure
Type
(1 0)
Amendment
(11)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
12 /17/15
l
Michael Foley
625 Court St #200
Clearwater, FL 33756
Pro -rata
Contribution Refund
pis
$32.67
17
12 17 15
/ /
Phil Henderson
1672 Winding Creek Rd
Dunedin, FL 34698
Pro -rata
Contribution Refund
Dis
$65.39
18
12
Janet Henderson
/17/15
2173 Louisa Dr
Belleair Beach, FL 33786
Pro -rata
Contribution Refund
Dili
$130.68
19
12 17 15
Grant Horvath
/ /
503 Palm Drive
Pro -rata
Largo, FL 33770
Contribution Refund
Dis
$65,34
20
12
Sandy Hutton
/17/15
4 Belleview Blvd #402
Pro -rata
Belleair, FL 33756
Contribution Refund
Dis
$32.67
21
12 17 15
Todd Jennings
/ /
1720 Indian Rocks Rd
Pro -rata
Belleair, F 33756
Contribution Refund
Dis
$32.67
22
12 17 15
Bruce Mitchell
/ /
1710 Cypress Ave
Pro -rata
Belleair, FL 33756
Contribution Refund
Dis
$163.35
23
12
Kathleen Peters
/17/15
6800 Gulfport Blvd S #200
Pro -rata
South Pasadena, FL 33707
Contribution Refund
Dis
$163.35
24
DS -DE 14 (Rev. 11113)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name Doreen DiPolito (2) I.D. Number
2015
11 01 201 12 Page (3) Cover Period / / { through ! 17 / (4) Pa a of
5
(6)
Date
(7)
Full Name
(8)
Purpose
(add office sought if
contribution to a
candidate)
(a)
Expenditure
Type
(10)
Amendment
(11)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
12 /17 / 15
Les Rubin
3026
Pro -rata
Contribution Refund
Dis
$65.34
25
Oakmont Dr
Clearwater, FL 33761
12 17 15
/ /
Suzy Sofer
569 Cortez Ave
Pro -rata
Contribution Refund
Dis
$49.00
26
Belleair Bluffs, FL 33770
12 /17 / 15
Sunrise Holdings of Clearwater
100 Oakmont Ln #103
Belleair, FL 33756
Pro -rata
Contribution Refund
Dis
$163.35
27
12 17 15
I/
The Consus Group LLC
PO Box 4268
Clearwater, FL 33758
Pro -rata
Contribution Refund
Die
$130.68
28
12 / 17 / 15
Jimmy Walker
5795 Ulmerton Rd #200
Clearwater, FL 33760
Pro -rata
Contribution Refund
Dis
$65.34
29
12 / / 17 15
Kiefer Woods
17315 Kennedy Dr
North Redington, FL 33708
Pro -rata
Contribution Refund
Dis
$32.67
30
12 17 15
/ /
Cody's Belleair
2530 West Bay Dr
Largo, FL 33770
Pro -rata
Contribution Refund
Dis
$32.67
31
12 /17)/ 15
Georgie Menke
8067 Sugar Bear Trail
Palm Harbor, FL 34681
Pro -rata
Contribution Refund
pis
$ifi.34
32
DS-DE 14 (Rev. 11113)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name Doreen DiPolito (2) I.D. Number
(3) Cover Period 11 / 01 / 2015 through 12 / 17 / 2015
(4) Page 2 of
5
(5)
Date
(8)
Sequence
Number
(7)
Full Name
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
(8)
Purpose
(add office sought If
contribution to a
candidate)
(9)
Expenditure
Type
(10)
Amendment
Amount
12 /17 / 15
09
Lee Arnold
311 Park Place Blvd
Clearwater, FL 33759
12 17 / 15
10
Brian Aungst, Jr.
1683 Midnight Pass Rd
Clearwater, FL 33765
Pro -rata
Contribution Refund
Dia
$326.71
Pro -rata
Contribution Refund
Dia
$326.71
12 /17 / 15
11
Debra Bellmaine
406 Magnolia Dr
Clearwater, FL 33756
Pro -rata
Contribution Refund
Dia
$32.67
12 /17 / 15
12
Julie Burnside
885 Harbor Island
Clearwater, FL 33767
Pro -rata
Contribution Refund
Dis
$49.01
12 /17 / 15
13
Concessions Pier 60
PO Box 3337
Clearwater, FL 33767
Pro -rata
Contribution Refund
Die
$326.75
12 /17 /15
14
Jeff Crupper
569 Cortez Ave
Belleair Blufffs, FL 33770
Pro -rata
Contribution Refund
Dis
$32.67
12 /17 / 15 Echelon Real Estate Svcs
235 3rd St S #300
St Petersburg, FL 33701
15
Pro -rata
Contribution Refund
Dis
$326.71
12 /17 / 15
16
Fields, Inc
PO Box 3337
Clearwater, FL 33737
Pro -rata
Contribution Refund
Dis
5326.71
DS.DE 14 (Rev. 11113)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name Doreen DiPolito
(3) Cover Period 11 / 01 /2015 through 12 / 17 / 2015
(2) I.D. Number
(4) Page 5
5
(6).
Date
(7)
Full Name
(8)
Purpose
(add office sought If
contribution to a
candidate)
(9)
Expenditure
Type
(10)
Amendment
(11)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
12 /17)(15
Jeanette Renfrow
22 Winston
Pro -rata
Contribution Refund
Dis
$65.34
33
Dr
Belleair, FL 33756
12 17 15
/ /
Paul Gibson
521 Mandalay Ave #610
Clearwater Beach, FL 33767
Pro -rata
Contribution Refund
Dis
$163.35
34
12 /17 / 15
Michael Mikurak
400 Beach Drive We #703
St Petersburg, FL 33701
Pro -rata
Contribution Refund
Dis
$326.71
35
12 17 15
/ /
Kara Behar
990 Bay Esplanade
Clearwater, FL 33767
Pro -rata
Contribution Refund
Dis
$98.01
36
/ /
/ /
/
/ /
DS -DE 14 (Rev. 11113)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Doreen DiPolito
Name
(2) 420 Druid Road West
(4)
Address (number and street)
Clearwater, FL 33756
City, State, Zip Code
L Check here if address has changed
Check appropriate box(es):
0
Candidate Office Sought:
❑ Political Committee (PC)
❑ Electioneering Communications Org (ECO)
❑ Party Executive Committee (PTY)
❑ Independent Expenditure (IE) (also covers an
individual making electioneering communications)
Y
NOV 0 9 2015
OFFICIAL RECORDS AND
LEGISLATIVE SR,; c S DEPT
(3) ID Number:
❑ Check here if PC or ECO has disbanded
El Check here if PTY has disbanded
❑ Check here if no other IE or EC reports will be filed
(5) Report Identifiers
Cover Period: From 10 / 01 / 2015 To 10 / 31 / 2015 Report Type: MI 0
Original ❑ Amendment
❑ Special Election Report
(6) Contributions This Report
Cash & Checks
Loans
Total Monetary
In -Kind
$ 5 , 775 00
(7) Expenditures This Report
Monetary
Expenditures
Transfers to
Office Account $
Total Monetary
00
(8) Other Distributions
(9) TOTAL Monetary Contributions To Date
$ , 5 , 775 . 00
(10) TOTAL Monetary Expenditures To Date
$ , 0 . 00
(11) Certification
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.)
I certify that I have examined this report and it is true, correct, and complete:
(Type name) Thomas Kiernan (Type name) Doreen DiPolito
❑ Individual (only for IE
or electioneering comm.)
O
Treasurer 0 Deputy Treasurer
Xr170a.7n.1� -.,.
Signature
Candidate
X
Signature
❑ Chairperson (only for PC and PTY)
DS -DE 12 (Rev. 11/13)
SEE REVERSE FOR INSTRUCTIONS
(1) Name
CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS
Doreen Dipolito
(2) I.D. Number
10 01 2015 10 31 2015
/ /
(3) Cover Period / / through
(4) Page
5
of
(5)
Date
(7)
Full Name
(8)
Contributor
Type Occupation
(9)
Contribution
Type
(10)
In -kind
Description
(11)
Amendment
(1 2)
Amount
(6)
Sequence
Number
(Lest, Suffix, First, Middle)
Street Address &
City, State, Zip Code
10 13 2005
/ /
Jennings, Todd
1720 Indian Rocks Rd
I
CHE
50.00
01
Belleair, FL 33756
10 13 2015
/ /
Debra Bellmaine
406 Magnolia Dr
I
CHE
50.00
02
Clearwater, FL 33756
10 13 2015
/ /
Foley, Michael
625 Court St #200
Clearwater, FL 33756
I
CHE
50.00
03
10 13 2015
/ /
Crupper, Jeff
569 Cortez Ave
Belleair Bluffs, FL
33770
I
CHE
50.00
04
10 13 7015
/ /
Cody's Be2lea.zr
2530 West Bay Dr
Largo, FL 33770
B
CHE
50.00
05
10 13 2015
/ /
Hutton, Sandy
4 Belleview Blvd #402
Belleair, FL 33756
I
CHE
50.00
06
10 13 2015
/ /
Woods, Keifer
17315 Kennedy Dr
N Redington Beach, FL 1
33708
CHE
50.00
07
no_ 11C n4 in_.. •.f.1)\ - -- - --
OR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
Doreen DiPolito
(1) Name
(2) I.D. Number
10 01 2015 10 31 2015 2 5
1 (4) Page of
(3) Cover Period / / through
-DE 13 (Rev. 11/13)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(5)
Date
(7)
Full Name
Contributor
Type
(8)
Occupation
(9)
Contribution
Type
(10)
In -kind
Description
(11)
Amendment
(12)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
10
13
2015
Sofer, Suzy
/
/
569 Cortez Ave
Belleair Bluffs, FL
I
CHE
75.00
08
33770
10
13
Burnside, Julie
/
/2015
885 Harbor Island
Clearwater, FL 33767
I
CHE
75.00
09
10
13
Horvath, Grant
/
,2015
503 Palm Drive
Largo, FL 33770
I
CHE
100.00
10
10
13
Armstrong, E.D.
/
/2015
1614 Santa Barbara Dr
Dunedin, FL 34698
I
CHE
100.00
11
10
13
2015
Rubin, Les
/
/
3026 Oakmont Dr
Clearwater, FL 33761
I
CHE
100.00
12
10
13
2015
Walker, Jimmy
/
/
5795 Ulmerton Rd #200
Clearwater, FL 33760
I
CHE
100
13
10
13
2015
Henderson, Phil
/
/
1672 Winding Creek Rd
Dunedin, FL 34698
I
CHE
100.00
14
-DE 13 (Rev. 11/13)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(1) Name
CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS
Doreen DiPolito
(2) I.D. Number
10 01 2015 10 31 2015 3 5
(3) Cover Period / / through / / (4) Page of
(5)
Date
(5)
Sequence
Number
(7)
Full Name
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
(8)
Contributor
Type Occupation
(9)
Contribution
Type
10 13 2015
/ /
15
Henderson, Janet
2173 Louisa Dr
Belleair Beach, FL
33786
I
Realtor
CHE
(10)
In -kind
Description
Amendment
(12)
Amount
200.00
10 13
2015
16
The Corsus Group LLC
PO Box 4268
Clearwater, FL 33758
B
Gov: Consult
CHE
200.00
10 13 2015
/ /
17
Anastasopoulos, Elias
1600 Gulf Blvd
Clearwater, FL 33767
I
Developer
CHE
250.00
10 13
2015
18
Peters, Kathleen
6800 Gulfport Blvd S
*201 -331
S Pasadena, FL 33707
I
Legislator
CHE
250.00
10 13 2015
/ /
19
10 13 2015
/ /
20
10 13 2015
/ /
21
Sunrise Holdings of
Clearwater
100 Oakmont Ln *103
Belleair, FL 33756
Mitchell, Bruce
1710 Cypress Ave
Belleair, FL 33756
Aungst Jr., Brian
1683 Midnight Pass Way
Clearwater, FL 33765
DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
I
B
Holding Co.
Realtor
Attorney
CHE
CHE
CHE
250.00
250.00
500.00
1
(1) Name
CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS
Doreen DiPolito
10 01 2015
(2) I.D. Number
(3) Cover Period / / through
10
/ 31 / 2015
(4) Page 5 of 5
ev.
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(5)
Date
(7)
Full Name
&
Contributor
Type
(8)
Occupation
(9)
Contribution
Type
(10)
In -kind
Description
(11)
Amendment
(12)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address
City, State, Zip Code
10
1
30
2015
/
Mikurak, Michael
400 Beach Drive NE
#703
33701
1
Retired
CHE
500.00
29
St Petersburg, FL
/
/
/
/
/
/
/
/
/
/
/
/
ev.
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS
Doreen. DiPolitc
(1) Name
(2) I.D. Number
10 01 2015 10 31 2015 4 5
(3) Cover Period / / through / / (4) Page of
DS -DE 13 (Rev. 11/13)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(5)
Date
(7)
Full Name
Contributor
Type
(8)
Occupation
(9)
Contribution
Type
(10)
In -kind
Description
(11)
Amendment
(12)
Amount
(6)
Sequence
Number
(Last, Suffix, First, Middle)
Street Address &
City, State, Zip Code
10
13
2015
Concessions Pier 60
/
/
PO Box 3337
Clearwater, FL 33767
B
Concessionai
CHE
500.00
22
10
13
2015
Fields, Inc.
/
/
PO Box 3337
Clearwater, FL 33767
B
Food Service
CHE
500.00
23
10
13
2015
Arnold, Lee
/
/
311 Park Place Blvd
Clearwater, FL 33759
1
Real Estate
CHE
500.00
24
10
13
2015
Echelon Real Estat Svcs
/
/
235 3rd St S $300
St Petersburg, FL 33701
B
Real Estate
CHE
500.00
25
10
30
2015
Nenke, Georgie
/
/
8067 Sugar Bear Trail
Palm Harbor, FL 34681
I
25.00
26
10
30
2015
Renfrow, Jeanette
/
/
22 Winston Dr
Belleair, FL 33756
I
100.00
27
10
30
2015
Gibson, Paul
/
/
521 Mandalay Ave #610
Clearwater Beach, FL
1
Realtor
250.00
28
33767
DS -DE 13 (Rev. 11/13)
SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
WAIVER OF REPORT
(Section 106.07(7), F.S.)
(PLEASE TYPE)
t
C Ci L RECORD. ':')
L`:' SL '
Doreen DiPolito Clearwater City Council Seat 2
Name Office Sought
420 Druid Rd W. Clearwater, FL 33756
Address
City State Zip Code
Candidate 0 Political Committee 0 Party Executive Committee
NOTE: This form does not apply to an electioneering communications organization (ECO). An ECO must file a report (rot a
waiver) that no reportable contributions or expenditures were made during the reporting period (s. 106.0703(6), F.S.).
❑ Check here if address has changed since last report. ❑ Check here if PC has DISBANDED and will no longer file
reports.
TYPE OF REPORT (Check Appropriate Box and Complete Applicable Line beneath Box)
in MONTHLY REPORT fl PRIMARY ELECTION IJ GENERAL ELECTION ® OTHER REPORT TYPE
Indicate report # Indicate report* Indicate report*
M9 P G
❑ TERMINATION REPORT ❑ SPECIAL ELECTION
Indicate report type and #
as applicable:
NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF
September 24, 2015
THROUGH September 30, 2015
REQUIRED SIGNATURES FOR
9 cT2015
Date
Signature Date
Candidates:
Candidate and Campaign Treasurer or Deputy Treasurer (s. 106.07(5), F.S.)
Political Committees:
Chairman and Campaign Treasurer or Deputy Treasurer (s. 106.07(5), F.S.)
Party Executive Committees:
Treasurer and Chairman (s. 106.29(2), F.S.)
Except as noted above for an ECO, in any reporting period when there has been no activity in the account (no funds expended or
received) the filing of the required report is waived. However, the filing officer must be notified In writing on the prescribed
reporting date that no report is being filed.
DS-DE 87 (Rev. 06/15)
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
1707: M
c o
077IC%1',I I" E@ a S ANn
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
X Initial Filing of Form Re- filing to Change: EJ Treasurer /Deputy : Depository Office Party
2. Name of Candidate (in this order: First, Middle, Last)
Doreen Hock - DiPolito
3. Address (include post office box or street, city, state, zip
code)
420 Druid Road West
Clearwatrer, FL 33756
4. Telephone
(727 ) 423 -9969
5. E -mail address
doreen.dipolito @d - mar.com
6. Office sought (include district, circuit, group number)
Council Clearwater Seat# 2
7. If a candidate for a nonpartisan office, check if
applicable:
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 X
No Party Affiliation E1 Party candidate.
9. I have appointed the following person to act as my X Campaign Treasurer JJ Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
Thomas M. Kiernan
11. Mailing Address
569 71st Ave N.
12. Telephone
( 727 ) 422 -1345
13. City
St. Petersburg
14. County
Pinellas
15. State
FL
16. Zip Code
33702
17. E -mail address
tmkiernan @hotmail.com
18. I have designated the following bank as my Primary Depository Secondary Depository
19. Name of Bank
US AmeriBank
20. Address
PO Box 17540
21. City 1
Clearwater
22. County
Pinellas
23. State
FL
24. Zip Code
33756
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 FACTS STATED IN IT ARE TRUE.
25. Date
26. Signat
X
re
of C did
—
27. Treas rer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
I Thomas M. Kiernan , do hereby accept the appointment
(Please Print or Type Name)
designated above as: X Campaign Treasurer Deputy Treasurer.
2IS P2oi5 X)14....o ri.-7 .,„,,,:,
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S- 2.0001, F.A.C.