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Humphrey, Sammy Ray Ji\ Appointment of Political Treasurer For State and Local Candidates and Single-Candidate Committees INSTRUCTIONS The Appointment of Political Treasurer statement must be used to appoint a political treasurer as required by the Campaign Financial Disclosure Act (T.C.A. § 2-10-105) for state and local candidates and single- candidate political campaign committees. A state candidate may not receive or expend funds for an election until a political treasurer has been appointed for that election. A local candidate pursuant to T.C.A 2-10-10 1, may be exempt from completing this form, please checkwith county election commission for more information. A candidate may appoint himself or herself as political treasurer. A new form must be filed if the treasurer is changed. Candidates for state public office must file their original Appointment of Political Treasurer statement ONLY with the Registry of Election Finance, 404 James Robertson Parkway, Suite 104, Nashville, TN 37243-1360. Candidates for local public office must file their original Appointment of Political Treasurer statement ONLY with their county election commission. 1. Date: 2. Name of Candidate or Co mittee: 3. Candidate e-mail address: 4. Campaign Address and Phone: City State Zip Code Phone -7Y60 7zlo S. Home Address and Phone (if different than item 4 above): City State Zip Code Phone 6. Office Sought (include district number, if applicable) 7. Parry Affliation 8. Election Year C n~ /,mar>~, L~, 9. Treasurer Name: 10. Treasurer e-mail address: U ?d;~✓~~ jG~r`1/u ~ ct,1;r~Pr~c'~('u~%/i UItifJ_,,v~~ 11. Treasurer Address and Phone: City State Zip Code Phone 12. Candidate and Treasurer Signature (both signatures must be witnessed. Treasurercan not witness candidate's signature): Signature of Candidate Signature of Treasurer Signature of Witness Signature of Witness Registry of Election Finance SS-1120 (rev 1012010) FINANCIAL DISCLOSURE STATEMENT EXEMPTION Pursuant to TCA § 2-10-101(b) a candidate is exempt from filing financial disclosure statements: "If a candidate is seeking an office for which service is part-time, compensation is less than $1,000 a month, and the candidate does not spend more than $1,000 to get elected to office, the candidate does not have to file Campaign Financial Disclosure Reports." CANDIDATE'S INFORMATION: APR `v Candidate's Name: Z Candidates Position: C ©:lx4-s, _5Ugo.' P(24)w 0 o -r Residential Address: jS'yZ DAv;5 lU City State: TN Zip: I hereby state that I meet the above qualif ications for exemption and am therefore exempt from filing financial disclosure statements. Candidate Mg ature Date ~t- 3-ly Witness's Signature Date If my plans change and I realize I will spend more than $1,000 on my campaign, I will immediately make a financial disclosure report.