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Polglaze, Jay Edwin - Seat 3CAMPAIGN TREASURER'S REPORT (1) j( e- all)iY--) //c,laL-EC / v ! -._c1G SUMMARY w ofFI ».a4 "' Name J (2) 5-;;;2-, /CIA 1:112-Pc: 74tO • Address (number and street) CL ) FL 7 ) City, State, Zip Code` ❑ Check here if address has changed (3) (4) Check appropriate box(es): Lv� he c;andidate Office Sought: /-F .!j,r- TE= }2 QJ ID Number: 4-7-- 5-3 0080 -r coax C( L_ s+ `- '-JT 3 J d ❑ Political Committee (PC) ( ❑ Electioneering Communications Org. (ECO) ❑ Check here if PC or ECO has disbanded ❑ Party Executive Committee (PTY) ❑ Check here If PTY has disbanded ❑ Independent Expenditure (IE) (also covers an ❑ Check here if no other IE or EC reports will be filed individual making electioneering communications) (5) Report Identifiers Cover Period: From / , 7 / (90 (4 To / /6 / ,20/6 Report Type: 0,1;� -.26/6 ❑ Original ❑ Amendment ❑ Special Election Report (6) Contributions This Report Cash & Checks $ , ,4 • 00 (7) Expenditures Monetary Expenditures Transfers Office Account Total Monetary This Report $ , 7 ,4__c.. . Loans $ , , to $ , , Total Monetary $ , , . $ , 9. /-C. , In -Kind $ , , (8) $ Other Distributions , , . (9) TOTAL Monetary Contributions To Date $ ,.„24 ,175- . on (10) TOTAL Monetary Expenditures To Date $ ,c3 ,i3c) .z2 (11) Certification It is a first degree misdemeanor for any person 1 certify that I have examined this report d it is true, correct, (Type name) �,_ l�) in D C to falsify a public record (ss. 839.13, and complete: (Type me) W) ✓1 F.S.) j I l IG�I.Z • Individual (only for IE Treasurer • De. • • Treasurer Candidate X `i? ' ignat • Chairperso :R''• for PC and PTY) �(v or electioneering comm.) C,. X _ -� t �. / lite re v- _ wr Si. • _turn D9'DE 12 (Re . 17/13) SEE REVERSE FOR INSTRUCTIONS (1) Name Cs CAMPAIGN TR.EASyRER'S REPORT - ITEMIZED EXPENDITURES J� Zd U)i (2) I.D. Number 1.7— 5--)306 �� (4) Page / of j (3) Cover Period IeV-- L9-7 4,20i /o through 03 / /U / &// DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (5) Date (7) Full Name (8) Purpose (add office sought if contribution to a candidate) (9) Expenditure Type (10) Amendment (11) Amount (g) Sequence Number (Last, Suffix, First, Middle) Street Address & City, State, Zip Code 3 / / /.h '' c ems -. Pe try mlu 7? 4/4 (2c0 TALL ?(A) , t_A6 ; 3377/ / / / / / / / / / / / / / / / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS JC.q eciw;n1 Liz (3) Cover Period D,2. / a7 /�2/ j, through 03 / /0 (2) I.D. Number 1-7--5:2,3t)080 /kb/ , (4) Page ( of / (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number v3/2 1/b7 6 )1c\2 D -)5 P4i7 ? 12 ci_w'R 1:---t ?3, y CHI t 0 OCR / D3 1 ?" //6. STE-40V Lie c;l e Dm -s g: cau , 15- AI tsa4,1,e) t f-K6.n (__ 3377) 3 044- 5" .cep / / / / / / / / / / DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES Jay Polglaze Campaign 522 Richards Avenue Clearwater, FL 33755 1(5 L CAMPAIGN TREASURER'S REPORT (1) Jj tflWIV Po I 2 SUMMARY Oc tp `iR 08 2�i (, ,= !aiy1 RECORDS AND LEGISLATIVE StcVCS DEPT Name f� (2) . 1 - 0104 X15 ,4(%Ij—. Address (number and street _. 3 _ City, Stat-, Zip Code ❑ Check here if address has changed (3) (4) Check appropriate box(es): IEKandidate Office Sought: _ ,. , ! Tt 12-- C ❑ Political Committee (PC) ❑ Electioneering Communications Org. (ECO) ❑ Check ❑ Party Executive Committee (PTY) ❑ Check ❑ Independent Expenditure (IE) (also covers an ❑ Check individual making electioneering communications) ID Number: 47 —5,9--300 �t C-I l., C t\--1- 3 here if PC or ECO has disbanded here if PTY has disbanded here if no other IE or EC reports will be filed (5) Report Identifiers Cover Period: From / /3 /26/ b To / a 4, / 00 /6 Report Type:/973;;X/6 ❑ Original ❑ Amendment ❑ Special Election Report (6) Contributions This Report Cash & Checks $ , , 5—U0 . 00 (7) Expenditures Monetary Expenditures Transfers Office Account Total Monetary This Report $ , / , V • Loans $ • to $ • Total Monetary $ , 3 , • 66 $ , / '22-(2— In -Kind $ (8) Other Distributions $ . (9) TOTAL Monetary Contributions To Date $ , a5 , 3:75• oa (10) TOTAL Monetary Expenditures To Date $ , / _._ (11) Certification It is a first degree misdemeanor for any person I certify that I have` examined this report and it is true, correct, (Type name) J a.. a I') ! C hz ' Y to falsify a public record (ss. 839.13, F.S.) and complete: /I 1 laze (Type - . e) 0 gd (�vi n , • Individual (only for IE Treasurer • Dep tyeasurer E Candidate • Chairperson (o• - =nd PTY) or electioneering com • r / � gnatur_ i gnat e S -DE 12 (R 7 SEE REVERSE OR INSTRUCTIONS (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS Ca U3 n )y cc (2) I.D. Number 2-1-7 -5 -500f0 (3) Cover Period _9 / / 3 / /, through / / / (4) Page / of 2- (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number / // /.0/‘, �►2co e7) 79s-69- /, B � Q, 11-L. 1 eft- S6a� oc� 3 r 8 /0 ws ()Craft_ a --3- - >> kp /oo .9 /ls— / / 4 a-o /6 G-tz xDoio-- s irk nJ(- r»MIL,gm2'10-77b ltL /oo.ob / /7 /) 7P -Vlb Nk A-1 ,/ !7 / 5, CL u 53767 /ad r °C) °/ 02 / /7 //6 gezbi-c)14-c4 /660 A MN_ ut .7-5---5--- lC c.u,�2 FL 5 yc L' �� -COQ / `_� / /yB z/ ."T•1Y.1- 9r. P� g376 3 e-0- 5-60.00 c2 /°24c' / /, i 16-44 -ra <,UC3-(e.._ CLLt2 -67. G rew-/t.42 -- c H-� .3"--0 'QC) DS -DE 13 (Rev. 11113) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name (3) Cover Period / / through (2) I.D. Number / 5--73 60PC) / / (4) Page 2 of ?/ (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 3 / / //, Y' 1.4?-/?----/o13-.— /020C LL S LL 1=L 5-5-- wtoe- C(4-L� 5-ooe 0c.) g 3/ 5 1( p poe l L ilk). vc C Alt -r t t 7- 7 0,- s —,,,,, i A O2t � GL 3 Z 2 t +tom J , 00 7 3 / ` l i FMAJK W(- Yd /' Lio? Leomere b C 332`7 CO- L , - W. 0 0 / 0 / / / / / / / / DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TR URER'S REPORT - ITEMIZED EXPENDITURES (1) Name jCvy ( . � y1 f Ircz c e (2) I.D. Number 47-5; 3 apc9 (3) Cover Period / i3 00/6 through i 2/ /_2/, (4) Page / of / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (5) 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 /6 / / /hc(tCeaN 2t)51.3 TFICC_ j , /4- Lh- Go j 3377 / C/'tl� / � /� / / / 6-0- 37- J�1? 1;1i) f/ 20s 0 "TN- P,N.s�� - cN-IJ yo 1, z-- / / / / / / / / / / / / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES Jay Polglaze Campaign 522 Richards Avenue Clearwater, FL 33755 CAMPAIGN TREASURER'S REPORT (1) JQj -k(k)i ) Q lC� tcf..z.-e SUMMARY OFFI =''* '� � * , B 14 201b OFFICIAL RECORDS AND LEGISLATIVE SR\(CS DEPT Name •J (2) _522 R l Criti iii S Av.. Address (number and street) CLEA wfY I J 337S5� ) City, State, Zip Code ❑ Check here if address has changed (3) (4) Check appropriate box(es): //�� 2andidate Office Sought: Q l ' � RWfi\1 t.R C,LTL( ID Number: 11-7-5—O30080 COC1[ C(L �t� A r 3 ❑ Political Committee (PC) ❑ Electioneering Communications Org. (ECO) ❑ Check here if PC or ECO has disbanded ❑ Party Executive Committee (PTY) ❑ Check here if PTY has disbanded ❑ Independent Expenditure (IE) (also covers an ❑ Check here if no other IE or EC reports will be filed individual making electioneering communications) (5) Report Identifiers Cov Period: From a / / / /6, To a / /a / /(,„ Report Type: vvi /_z0/6 Original ❑ Amendment ❑ Special Election Report (6) Contributions This Report Cash & Checks $ , .I- 300 • 0 0 (7) Expenditures Monetary Expenditures Transfers Office Account Total Monetary This Report $ , /0 , ye?q • 30 Loans $ , to $ • Total Monetary $ , Lp ,300. O $ , /0 y?% 30 In -Kind $ • (8) Other $ Distributions , , (9) TOTAL Monetary Contributions To Date $ , D-� , C73. 00 (10) TOTAL Monetary Expenditures To Date $ , , 3 , 9� . 3 (11) Certification It is a first degree misdemeanor for any person I certify that I have examined this report and it is true, correct, (Type name) to falsify a public record (ss. 839.13, F.S.) and complete: (Type name) • Individual (only for IE ‘surer ❑ Deputy Treasurer andidate X • Chairperson only for PC and PTY) or electioneering comm.) X ► fdl/i4.7 L �' E� irliA/40L Si• • -tur- ignat re 0' ev. SEE REVERSE FOR INSTRUCTIONS (1) Name CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS jay &cuin I1/at (2) I.D. Number 47- 5-a3001d (3) Cover Period 09. / / / /6, through _2 / / 2 / / (a (4) Page / of 5 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number / (PX55.,1/ /1 SAC. _ 33c/ 89-51- %}4' .fp2 CONS 71Avi'"' c AL' /00, 06 / Ccx15u.LT /fti& / V,.Qsfel:tr. 4605 -- 33760 B eon-va egg- Jot o a v2. , j , / 6 rpclor_trea=y 62,— ecag 7 ec 37- 1 E sa 00 3 Z. , 8 ,l 3,e 0A) Iced /696��3e:5 f)CcTo iz A�� ems' 500 0 6 4- 2, 8 , l 6 licts i Mph zs -5 ilia 3Q_/+ 3 coot .(.0 -Ayr I S ��O` °� 5 Z 18 ,i 6 F.66 Sc.V1< 831 P -2 . yim f=c- 3y6Q e�c� ico 6 a g ,16 A) /1iJ/& ZZL/ wafuwa yS ec.4.44 I t- 33767 tits" /0,00 1 -Ut l3 IKev. SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS J0,9 eaus ? yea (3) Cover Period / / through / / (4) Page 2 of 5- (2) I.D. Number 47-5360,0 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number Z,I, 8 /6 ‘e6`3-12..rivnaeY D' A) WPcagzTI 0 amaio i j 6-d / 33777 C 41. t75,00 8 g / di / /k eArDveM42 t (5" caa thi o n}, 5 4t4t6 y C.f +I� .500.00 Ai , /6 i ‘oitiiTtf ON Icto l0 68Ye5,111 ,337&7 ,'oc o o lb L� /0`213AS � 55 e- i 1 7 / 1 b tu K-lr - g-1,34-Z_ 30e, Qa iT) d C 3375-75 OckFri- t cxr 2 g, 7 ,/6 S RIjG�O ,S / 00 K,�1oN-ru) .- S6 ice �D� o p /3 2 , g , 6e /A)Fpucti /4-0 G figs L rJ fi Sia 3968 4 14- DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (3) Cover Period / / through / (2) I.D. Number (4) Page 7 -1300 of (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 1 / , a sorb .�A) X884 (V 337 C(W 160 .60 z / 6 , /6 Ftetoodil--_-0q1Av 407 Lew b 3-761 , / zo o /4 2 / 8 //6 s /cNtorsrpt /4s C 3376.E v,c,d3 if t7 2 , o , /6 PH-UL ( 6o I)u. ow ,� ,�.� '•' air X00,0 Q / S , -m76� a/7, /,o4„) w sF9 337(0 7 ma, zc �� p_oo,00 l S' /b2 fit` rPD'ac +4 337vg CN-� /00,00 / 8 , / , 6 PRI (_ 1 J " n 1- via: -� 9-1-73 1-o 1SA 7 .3e1(eut21t /1 046 * PoQ-� A `o , pp, o0 ?- 1 -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name J0J1 &LUJ lY) (2) I.D. Number 4-7-53.1300R3 (3) Cover Period / / through / / (4) Page 7 of (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 8 / /,b -RJLS 5ONf S xt33 • 5-75--, 5 -w X376 54"c1C e ►_‘ p,o Z 2 / 8 / (,b CV(/' 10k-sr / �ECtFt X3 37 5 1 03 -40'° b ;)3 /S , 16, W'1 -'E go veoGis125 97- Caul 357c4, e_k 5100 ;Li a—/ 8 / l b Ge - CA - Af {� (S 0 t- 3761 C1f-- /p. DO " , 1L-604 I bet- %33 C/u �,,> ' xL 26. ,; �� �� L ,moo, o e) 7 X73 mod 3375" 0/ / / 4JoYa v-S r a CI 5, 00 DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name J &Jou10 c 1aze (2) I.D. Number 47- 59`708c (3) Cover Period / / / / (p through & / / / / / (p (4) Page 5 of (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number d / n ' C FL 332- CtiE- / oo,o0 l a ,17 ,1k l vii) 1�-Rlrjnf3 a 17-P M. i --r e (AZ- c Ft 3-3767 Lr-tE-- /03,0(3 3 / / 6 , 1 H_S--oa_ Jv . ICJ(.- (- " 1`' /Z k.r G 1i L 5-60, v 0 3 / / / / / / / / / DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name r Po 19i QZ-e (2) I.D. Number LI 7 — 5o736Q j (3) Cover Period o2 / / / / b through (4) Page / of / (5) Date (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 71/ Pe (10) Amendment (11) Amount (6) Sequence Number 2 /X2 / /Co Gw.t- ST - 1.M Pe) MI NCr go-s s / R6-0/ FL 3377) C1N\ 9817.53 , i // (/ / 7-14E \-aoME - E`Po-[- `1195 CLrr i-o`( Cc-w R) F'L 33715 cf• 157, 02 a /8//10 G u-Lr L -L l j i .T-M PZ.l>g l r ,p050 TAC.(., 1 ► i s A- L}7) FC. 3377 / CAS 45 ,7,_5- / / / / / / / / / / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES JOM CAMPAIGN TREASURER'S REPORT (1) `ri o (r ?o1c' l? SUMMARY ! -. ,, • _ , Nam (2) 5--c9. //clf%2,�%1'�S »U(5, Address (number and street) 7Sl.Ss City, State, Zip Code ❑ Check here if address has changed (3) (4) Check appropriate box(es): E candidate Office Sought: I' X4/0 C / r y CY/WC ID Number: )17— 5a 30If20 /L.- Ste{ fki 3 ❑ Political Committee (PC) ❑ Electioneering Communications Org. (ECO) ❑ Check here if PC or ECO has disbanded ❑ Party Executive Committee (PTY) ❑ Check here if PTY has disbanded ❑ Independent Expenditure (IE) (also covers an ❑ Check here if no other IE or EC reports will be filed individual making electioneering communications) (5) Report Identifiers Cover Period: From Q t / 0/ / (t // To 6/ / 3/ / ,39,0/ (o Report Type: in / j`f Original ❑ Amendment ❑ Special Election Report (6) Contributions This Report Cash & Checks $ , a , 360. 5-0 (7) Expenditures Monetary Expenditures Transfers Office Account Total Monetary This Report $ , / , 9/7 . 17/0 Loans $ , , ' to $ . Total Monetary $ , , • $ . In -Kind $ , , - (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date $ ,lg , . © O (10) TOTAL Monetary Expenditures To Date $ , ,963 . ! 2 (11) Certification It is a first degree misdemeanor for any person I certify that I have examined this report and it is true, correct, (Type name) J C 0 / to falsify a public record (ss. 839.13, F.S.) and complete: 1 r (Type ame) .J ed ou i fl 1 e / ■ Individual (only for IIE rea urer ■ puty Treasurer andidate X • Chairperson ily for PC and PTY) or electioneering comm.) X _ fi �iil: r . natur: i Si ature DS -DE 12 (Rev.'11 /13) SEE REVERSE FOR INSTRUCTIONS (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS Joul &LU; n i/ae (3) Cover Period b j / 01 / vo46 through ® / 3 / / 2p/ , (4) Page / of / (2) I.D. Number 47— 5-30010 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number l l il l /4, CL WT / /�i% .erin`Q C`o r 3e /lee/2,..36 titre Cfre- /57J` 00 -Pele3-r+c 01 27-1/ bibit'W 7 s Cult eco 33-767 Z cl -tom-' 72,/3 ,/s P ()/JAJ A( w tuiLic Ft- 33767 co CMf- Cil. ,,,co ,,c) 0 3 / ,.29, /f, c Ol_ty 2q ?thee sr Spifely W n- , C(k �� (c0,0c) 4 / , ag ,1 k GCC-02 - 113o ca-vechAD 3 3755- r PbCrrac l fi(o) Co lm riles et4c (060. 0?) S / , 3 l ,o Nn A ,rrgee- "x,00 6 /384 2Z I. Fc .N663 "Bo\,c qj.s I CgysFir -13 3/6&/ Z 0- C it 500 DO DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN THE RER'S REPORT - ITEMIZED EXPENDITURES (1) Name e ; © gaz`e (2) I.D. Number 4-7-5;?3D O (3) Cover Period 0 / 0(1 14 through d/ / 3 / / (4) Page ( of / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (5) Date (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 (11) Amount (6) Sequence Number 1 /3 / //f 6"0 CPK id t Ina- Pi / • I4 &C) //fi g IVVa / / / / / / / / / / / / / / / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN REASURER'S REPORT (1) ja 61(,(»/9 1 Obz_ SUMMARY firrtt- V.PliSY s,,L..-• -,-,...: v ,.--,,,, Ai,.i LGZLA'fi'vci:: Name (2) 5 .2 Ricivie-gb-c AV , Address (number and Areet) -- 0 EAte \ 'OA TCX F--, 5--) 75 City, State, Zip Code Check here if address has changed (3) (4) Check appropriate box(es): andidate Office Sought: ID Number: z/7-5----oco EJ Political Committee (PC) fl Electioneering Communications Org. (ECO) fl Check here if PC or ECO has disbanded Party Executive Committee (PTY) El Check here if PTY has disbanded El Independent Expenditure (IE) (also covers an El Check here if no other IE or EC reports will be filed individual making electioneering communications) (5) Report Identifiers Cover Period: From 4.2 / p / / ,9 0 / — To ,'2 / .0 /5– Report Type: ) I 3 Original Ea‘nendment 0 Special Election Report (6) Contributions This Report Cash & Checks $ , ,. ,7o0. •ke, (7) Expenditures Monetary Expenditures Transfers Office Account Total Monetary This Report $ , , 705-7 6.) Loans $ , , • to $ . Total Monetary $ i I • $ . In-Kind $ , I • (8) Other Distributions $ , , . (9) TOTAL Monetary Contributions To Date $ , /3 ,415---. 00 (10) TOTAL Monetary Expenditures To Date $ , / , O l 3- . .- (11) Certification It is a first degree misdemeanor for any person I certify that I have examined this repo)t.nd it is true, correct, (Type name) ja,t4 glu.) 16 / to falsify a public record (ss. 839.13, F.S.) and complete: '----0 (Type name) J ' fd " t n 1 c, , 1 ( az ke • Individual (only for IE / reasurer E z, s ty Treasurer A w \ ;11clate • Chairpe s (on f. , PC and PTY) or electioneering comm.) NIs - / & .40/0 _ ignaturz ,,Signat re &-DE 12 (R4vA1/13) SEE REVERSE FOR INSTRUCTIONS (1) LL-41J CAMPAIGN TREASURER'S REPORT cui 13 R ka aZ `e SUMMARY q E 1 JAN 1 1 W$ [ q 1.ii�i � ( RECORDS LEGISLATIVE SRVCS DEPT Name / � (2) ��-ca i&IA —A p5 Avg- , Address �( /nuumber and street) _ FL. City, ❑ Check (4) Check �(,andidate ❑ Political ❑ Electioneering ❑ Party ❑ Independent individual State, Zip Code here if address has changed (3) appropriate box(es): n Office Sought: (J(._t/U R. C ! T`/ CO(,(,')C/ ID Number: it-7- -3c93U 0 L S /`-YT 3 Committee (PC) Communications Org. (ECO) ❑ Check here if PC or ECO has disbanded Executive Committee (PTY) ❑ Check here if PTY has disbanded Expenditure (IE) (also covers an ❑ Check here if no other IE or EC reports will be filed making electioneering communications) Cover Period: ❑ Original (5) Report Identifiers From 4_2„ / 0/ / ,204 To /i / 3 / / (90/,5- Report Type: f'4 ❑ Amendment ❑ Special Election Report (6) Contributions Cash & Checks Loans Total Monetary In -Kind This Report $ / ,/o---0 . p 0 (7) Expenditures Monetary Expenditures Transfers Office Account Total Monetary This Report $ , , 7U5 ,90 $ to $ . $ , • $ . $ • (8) Other Distributions $ . (9) TOTAL $ Monetary Contributions To Date // (10) TOTAL Monetary Expenditures To Date $ , / , 0/6". 6L (11) Certification It is a first degree misdemeanor for any person I certify that I have examined this report a • is true, correct, (Type name) ! G �� ..: /�L � to falsify a public record (ss. 839.13, F.S.) and complete: f 6:2 (Type name) j 6 edgily) � • Individual • y fo IE I�rreasurer ❑ De. , urfr - - ring co t� J andidate ❑ Chairperson (only fe C and PTY) 1 or electio Sign re / f :ignatu e 4 DS -DE 12 (Rev. 11 13) SEE REVERSE FOR INSTRUCTIONS (1) Name CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS wi� lal�laze (2) I.D. Number A/7- 5-.,736080 (3) Cover Period la- / n / /c9015- through 42_ /.5i 1 c s (4) Page / of (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number Pe --A/) tC OVER,,, t r / / 8 / /s t:74 �-n -S e 11C ,...6 0, o© M/}NNQQ/S iOTCL cz_ gui T1O!J /a /8 /15 ---5-IFF�, tZEWc�K�P��CS Le l ( s . (5-A4 E-n) +nr; INS- C N ET 7c�, c a (Lug F(_ 33 -1 ti /c 2 / / / / / 5' L. En, MeG / 1 /+7ra42A1-1 got j- / at-i- E 05D. a 6 3 //?c P IVV:i Q 356? /2- / /'2 / ! S� sFP F� W tlt'�"C xaS I we --'s *2-1- j +a7- 5E0ST t3 -3377y / // //s' AJO CH. pij e_72(LI,v it4-s- 6- Z ek , a C t-i2 ro,o, c O 5 3,01 ecio r- 337S-6 'a 1"/ 43-- - -Pkvs t Woc �inr Co e ;2 _ .7S S +C— J?z /1-- / 1l9 / / c6/ 30,c 6A" e -())...e4.3_6' 3 co\Laty ,,i,,.,...._. coo,co ./ DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name \J 6tai 1 17 /U�C� k22 (2) I.D. Number 47- 52 .3 co Oc (3) Cover Period / / p / /f5 --- through / 3/ / ZQ /5 (4) Page c of (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number / ? / y/A -TL: 5 ij--I rc� 6-120 C c.i2 P. I-+. q- 233 78 CC--D CSI A L t+ C MoD Dv 7 /,?._ / /Es 1 tc 'IVS91-- ! ( iN()." 7 v. tax /49 s^7 CL 1' 337/& C RE--7- /Do, 0 0 / / / / / / . / / / / DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (2) I.D. Number /7/7-3—e:930080 (4) Page / of / (1) Name (3) Cover Period 49 / o/ / /_5-- through l /72 /3 (5) Date (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 (11) Amount (6) Sequence Number //1/0 //. - sil i-T6 ry o(zT e)4,1Cd x3767 2 Cary / 3 x-62 /9/ /s/ s / l Ty o� i -E(2PS ,J� -, ,. 4-79-E C LA )_'- 3j 7-5-8 3/, /6 c. / / / / / / / / / / / / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIG N TREASURER'S REPORT (1) Joq(Lwir) /z SUMMARY O E V E- JJ tekL.. &t �.1�w� k ° "'C' `1 °` �'" " <3 LE L ATI . v S D Pi Nam (2) 5,9a /I C ti ff s Al/g- , Address (number and street) ()[,.w e F--z, . 3 a S City, State, ❑ Check here (4) Check appropriate Candidate ❑ Political Committee ❑ Electioneering ❑ Party Executive ❑ Independent individual making Zip Code if address has changed (3) box(es): Office Sought: (Lv/ ? (t-r-' 6,,c,Ljuc ID Number: 47- So ockco t L � j 3 (PC) Communications Org. (ECO) ❑ Check here if PC or ECO has disbanded Committee (PTY) ❑ Check here if PTY has disbanded Expenditure (IE) (also covers an ❑ Check here if no other IE or EC reports will be filed electioneering communications) Cover Period: From Q Original (5) Report Identifiers /7 / / /,0„.5---- To // / 30 / a0 /S' Report Type: /4 1 1 ❑ Amendment ❑ Special Election Report (6) Contributions Cash & Checks Loans Total Monetary In -Kind This Report $ , 7 , _fl5 -? ® $ , , (7) Monetary Expenditures Transfers Office Account Total Monetary Expenditures This Report $ , , I D - 4-- to $ . $ , , - $ , ,*310 - y9__ $ , ' , • (8) Other Distributions $ , , • (9) TOTAL Monetary Contributions To Date . , 7,,3- . 0 0 (10) TOTAL Monetary Expenditures To Date $ , , 3/0 . ¢a _10" It is a I certify that I have (Type name) . (11) Certification first degree misdemeanor for any person examined this report and it is true, correct, in �J to falsify a public record (ss. 839.13, F.S.) and complete: (Type name) ��GUt it ( z `�_ • Individual (only for IE Treasurer • t uty Treasurer Candidate ( • Chairperson (o r PC and PTY) or electioneering comm.) X � Si! atur (i / J ' Irr • / / tJi Signa ure I / DS=DE 12 (R ¢v. 11/13) SEE REVERSE FOR INSTRUCTIONS (1) Name CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS _13 lecz_c_ (3) Cover Period / / / / / /5-'--"through / / / 30 (2) I.D. Number �7 5,20$0 C / c /:5 (4) Page ( of 5— (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number c.,6 r,iga. TfAi&— (362.5- jcor vD ,3_3 7 6 f1, ii�J i bl,c)frittli yevel C ti L^ 1l / 05 / j M (Ctlf��e L (P, � iov 560,o0 // / o6 //.S s Hi v-4 . Isu(1 OlOrrIrn 33) e fete lava 6v-� 337x5 ,- L' 3 ��C ' l /� fA /S°'n /c.4 .0Q14 f+f.iM 2L(- UJi nDv09eZD 1 C(-14L (06,00 (7 l 9 / rs KA' J PONG.SIT 2_633 i 3 e F n 74. u.133cI T 11.L- C(A% /Of o6 S ( 7, ( 0 /�5 m ow n LO' 'i Sosr� as orrvUJi p e , -- da CL/P— 33"7 s15-- f �� ��� 7 ,fox 4-2- 68 3758 DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (3) Cover Period e- (2) I.D. Number 47 5;30 FO / / / /J through /) / 3o / co(s"i (4) Page Z of (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & Cit , State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number /� 1 7b / / �'d TAiA A9(S1- Dtt 31-i6n Gq.,evyt2 c ,: 250,00 0 /) / /0 / /5' T°tfn► /ST'C12 32/e to ?oX C ac (-l- 337b7 L,-wY - c,--0-.- ,,j / , da 9 0 / it' / /5' `'11) Mfig 111b)3 -% // 1 Iv Irs FCC e 3� 61 iiv05 IC)t oo 1) 11 l o lc %N A, ikrfEG /9 /20 15ceKes44se. cN. / co, to / / A7 //$ f216 1- el'"(P c/0 4(0s, 13L VD 4-14 -moPr 9 ?60 6 r- CN�rr(c�C° ° d© l 3 11 l la / lC se 60 ( s. vlr, 9 331b 7 Oft .5�0.0c) lq DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (3) Cover Period icoatn (qh77-e, 1/ (2) I.D. Number 417-5( .5 6 J / /5-- 3 through // / 30 / ,.,96/3- (4) Page of 5- (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 11 / /0 / /S AA �� //''n , . � V785" _US oniet6 QLSSTAUU c tft 3(.0,00 C C S II ,/U ,l5 5 was 18;9 5 6 3 _eZ 33785 `Y C L'i 3�a6c� /% J1 / /e) /(C1 1) L1°6111 l61 601- p 0 g 2(1 33785 ' 2e�� Sao 60 7 1( , /0 i 15/ MIZAZ176.311jA0 1-7)., oc-5r C 00- ?COP O / / , , �' FPA k 1'/r`C�N . CH-t vflrs it CH-e- /9 // , /0 , >_' SY 3 (26-`f C vl L- ost n-e-ern"5 73-000 Cr-r6-6.1 3755 '� toot ad ° °`" 70 / / / O / ° ) P X26021 24 3'7og -�8 4 3 RW-- 251' C- C0 1 DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (3) Cover Period 0,(9)02,e_ (2) I.D. Number -7 - 604 / /5— through 1/ / 36 / 2 /S (4) Page I/ of 5� (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 11 / /D /5 ' ift' -'y(fa o 0 sit ,5.5 // l o l i-�� ArAJ �0y -PHl14(. i-/a7 Cain ic ,3,7 7 G tie (06, 06 03 l/ i /0 //5 5r�� /� `/ / X66 61.6(-- 397(/ 014-. /0O' od .2/../ 6,19 wt. 1;5 5 34W e la o d-S ✓/ !S SSe , n4 et./946-" P_,D cbZ 2 14 'fbgs' 6 Pi-k-t- ctv ,,,z).00 d') fl, 9, , /3-Ch ?I5le- S-uy tn5 ..e, C Hc` i 00 t / / / /d / /s -AUL be - etV b� UL t2 R -763 wf/Z couffre y ,€), 5, i4. (-7_ 30"7 DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES (1) Name CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS ecios i n ro I6J _ (3) Cover Period // / 0/ /,,VO /S-- through // / 30 (2) I.D. Number 4-7 — ,?‘00gb / c;,90(5---- (4) Page of 7 (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number // / /U 116 F /LLUs Tiv( DBA ale(-?- CLv� a 1:--c_ D76% -EP€t-N CA-}- 5oo, pc / / / /o / 1 5 C_C) l Cstc,,ti eLk,x,FL 26-7 cek c 5-(XD, 00 // / /0 / IS mil— ©;77 765" _SfVoN(Li.) t ti /co, o6 /7 /a / 15- *>t__ G-t CSC, /_) -c.91 NikikiDAQ 3'3 767 ° - 47 a L LJ-)2 F L 337x 7 S ct+ --.-- /oo, n o � 3 / / / / DS -DE 13 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN-T EASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name -)LL �j 6'hli t'O 0(2 ce (2) I.D. Number 7— S 008C) (3) Cover Period // / 0) /,90/3—through ll / ?o l9D /5 (4) Page / of 1 (5) Date (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 (11) Amount (6) Sequence Number /l /l6/ - CrrY 0 dcw2 to S• OSObLJ 'i: ‘ Caw C, E= L • 3 3756;, 310, 4-1 ( / / / / / / / / / / / / / / DS -DE 14 (Rev. 11/13) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT (1) Jay Edwin Po!glaze SUMMARY oFFREeF D NOV 0 9 2015 OFFICIAL RECORDS AND LEGISLATIVE SRvrg nEpT Name (2) 522 Richards Ave. Address (number and street) Clearwater, FL 33755 City, State, Zip Code ❑ Check here if address has changed (3) (4) Check appropriate box(es): Candidate Office Sought: Clearwater City Council ID Number: 47-5230080 Seat #3 ❑ Political Committee (PC) ❑ Electioneering Communications Org. (ECO) ❑ Check here if PC or ECO has disbanded here if PTY has disbanded here if no other IE or EC reports will be filed ❑ Party Executive Committee (PTY) • Check ❑ Independent Expenditure (IE) (also covers an ❑ Check individual making electioneering communications) (5) Report Identifiers /" --- 1° Cover Period: From 10 / 01 /2015 To 10 / 31 / 2015 Report Type: Election Report ✓ Original ❑ Amendment ❑ Special (6) Contributions This Report Cash & Checks $ , 3,200.00 (7) Monetary Expenditures Transfers Office Account Total Monetary Expenditures This Report $ , , 0 . 00 Loans $ , , 0.00 _ to $ , , 0 . 00 Total Monetary $ , 3,200.00 $ 0 . 00 In -Kind $ , , 0 .00 (8) Other Distributions $ , , 0 . 00 (9) TOTAL Monetary Contributions To Date $ , 3 , 200 . 00 (10) TOTAL Monetary Expenditures To Date $ , , 0 . 00 (11) Certification It is a first degree misdemeanor for any person I certify that I have examined this report and it is true, correct, (Type name) Jay Edwin Polglaze to falsify a public record (ss. 839.13, F.S.) and complete: (Type name) Jay Edwin Polglaze 0 Individual (only for IE B Tre- -user • Deputy Treasurer 0 Candidate 0 Chairperson o y for PC and PTY) X r�i R �91A. /it or electioneering comm.) X • Stur- igna ure t DdIIDE 12 (Rev' 1 /13) SEE REGERSE FOR INSTRUCTIONS CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS Jay Edwin Polglaze - 47- 5230080 (1) Name (2) I.D. Number 10 01 2015 In 3! 201 (3) Cover Period / / through / (4) Page of 1 DS -DE 13 (Rev. 11/13) SEE REVERSE FOR I (5) Date (7) Full Name (Last, Suffix, First, Middle) Street Address & City, State, Zip Code Contributor Type (8) Occupation (9) Contribution Type (10) In -kind Description (11) Amendment (12) Amount (6) Sequence Number 10 06 2015 / / Jay Edwin Polglaze 522 Richards Ave. Clearwater, Fl. 33755 Postal Clerk check 400.00 1 10 22 / 2015 / Rev. Fr. R. Swick 831 Peggy Ray Dr. Dunedin, Fl. 34698 Reverend check 200.00 2 10 30 1 2015 / Waters Edge Commercial. Group 600 Cleveland st. Clearwater Fl. 33755 B Real- estate cas 1000'00 10 30 / 2015 / Daniels Ikajevs 600 Cleveland St. I-C 7\littlZ rc 3"37 55 Real- estate cas 1000.00 10 30 / 2015 / v. Raymond Ferrara 611 Druid rd. e. Suite 105 check 100.00 5 Clearwater, Fl. 33756 10 31 / 2015 / II Brian Aungst Jr. 1683 Midnight Pass Way Clearwater, Fl. 33765 _1 Attory Check 500.00 6 / / DS -DE 13 (Rev. 11/13) SEE REVERSE FOR I Sobiect: DSDE 84 Date; October 16, 2015 at 2:41 PM STATEMENT OF CANDIDATE (Section 106.023, FS„) ipiease print or tyPei \'. candidate for the ofiice of OFFICE USE ONLY E(.0111 have been provided access to read and understand the red irements of Chapter 106, Florida Statutes. date Each candidate must file a statement with the Querying officer within 10 days after Me , Appointment of Campaign Treasurer and Designation of Campaign Depository is filed, Willful failure to file Mis form is a first degree misdemeanor and a civil violation of the Campaign Financing Act which may result in a fine of up to SUM; (ss. 106.190)(c). 106,2650), Florida Statutes ), 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. RPCF 1,. is rr° . r.° °" OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): a 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 post office box or street, city, state, zip code) /�, OL- }(,,Ver& R-' _ / 4. Telephone (7Y) )1 70 -3976 5. E -mail adss r. 2, Laq 5,94( 11 6. Office sought (include d` trict, circuit, group number) -�--( C /TV (OO-/UCI L St *r 3 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 ❑ No Party Affiliation Party candidate. 9. I have appointed the following person to act as my ErEampaign Treasurer ❑ Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer J0±V e -Win O i laz 11. Mailing Address L5 �• ie/c-e 9-eAs L t 12. Telephone (7.97) L/// -3 276 13. City �1�{//°��`/�I/I� t T/o •1�4�. County 4 [ r S 15. State 16. Zip Code 17. E -mail address �� /� �4 /7`/� ,y� -7� ✓� �//��p/� C C .2132/ , /G._ /Y�'1jJ� / ^L]�� 18. I have designated the following bank as my Er Primary Depository in Secondary Depository 19. Name of Bank � le 1 )_(-�l� b 20. Address 6c9_9, . - --�-_ 144wie AJL-, .ei. 21. City 0_,1,= k -r-' 2 County I .0 CL-C S 23. State FL , 24. Zip Code -3 375 - UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE ' 25. Date TU Obe 5-� 00 L5------ 26. Signature of Candidate X i i `� .�_ _ 27. Treasurer's Acceptance of Appointment In the �� L--2_-e- I, L.-) 01 - lank and chec the ape opriate block) , do hereby accept the appointment (Pleas Prin o ype Name) designated above as: Campaign Treasurer El Deputy Treasurer. /"� On e G - � t, X 1� / . A lri g ... v / Sign. ure of : mpaign reasur; or De• !�' " reas - Date DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C. 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. ECF-TVE D-‘) rnT 0,77:aU Eii:CaiDS AND LEcinArivE SWCS D771 OFFICE USE ONLY 1. C ECK APPROPRIATE BOX(ES): Initial Filing of Form Re-filing to Change: Fr-Treasurer/Deputy Ei Depository 0 Office 0 Party 3. Address (include post office box or street, city, state, zip code) „_-__3—,9r. iici4/4.1el, ,,c ,0 vei-7/ CL-7_e_ 4. Telephonl CCICL) (r) 5. E-mail dd e C Wi—Ci'QO 14)- reei PL-1 (W </t i7ci3i e 7D-61,4 0 0. -3 -3233— 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if —/V—IEVI TY72-- C-Cry MA/Licit. applicable: SEPT- 3 0 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 2. Name of Candidate (in this order: First, Middle, Last) 1:1 Write-In El No Party Affiliation 17( 9. I have appointed the following person to act as my Campaign Treasurer p Deputy Treasurer Party candidate. 10. Name of Treasurer or Deputy Treasurer JCU1 e_CLA 013k7 14-1/ 11. Mailing Address 13. City 14. County Clea124A/41-77--)C- 15. State tL 12. Telephone 3 16. Zip Code 373-5-- 18. I have designated the following bank as my 17. E-ma I address 90 c. 2_4k_ 1 Y7yaJktd Err:Primary Depository El Secondary Depository 19. Name of Bank 22. County J3 21. City 3qeid/091 20. Address c5 Tf 0/9 p f isofu 24. Zip Code 75-& 23. State F I , 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 Ociobe 61 Treasurer' ceptance of Appointme 27. I, designated above as: • `e— (Please or Type Name) Campaign Treasurer 26. Signature of Candidat ?fill in the ID la s and check e appr • riate b ock) X C b-“Z_ S-1 c=t)t,r Date / DS-DE 9 (Rev. 10/10) , do hereby accept the appointment Deputy Treasurer. Sign:lure of ampaig Trea r or De. /ty Treasurer Rule 1S-2.0001, F.A.C.