Birdwell, Denice H.
Print Form
OCT172011
s Q 7t01N, ? Appointment of Political Treasurer
'iF 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 2-10-101, maybe
exempt from completing this form, please check with 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: Name of Candidate or Committee: 3. Candidate e-mail address:
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4. Campaign Address and Phone: City State Zip Code Phone
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L001) 0
5. Home Address Phone (if different t an item 4 above): City State Zip Code Phone
A A - ~bck4 rck -TO a '1055 OJJ -1 -7 7 -400
6. Office Sought (include district number, if applicable) 7. Party Affliation 8. Election Year
hCKCL ~Om 11615~) ortt,•(' oZ (9 / C-)-
9. Treasurer Name: 10. Treasurer e-mail address:
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11. reasurer Address and Phone: City State Zip Code Phone
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r_v\~ -6 a JIM A5- 77-000
12. Candidate and surer Signature (both signatures must be witnessed. Treasurer can not witness candidate's signature):
Signature of Candidate Signature of Treasurer
Signature of Witness Signature of Witness
Registry of Election Finance
SS-1120 (rev 10/2010)
FINANCIAL DISCLOSURE STATEMENT EXEMPTION
Pursuant To TCA § 2=10-201(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 $500 a month and the candidates 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:
Candidate Name:
Candidate Position: ~.0 fri rwiz i U
Residence Address: )3 City: C"f'~- State: TN Zip: fN
I. hereby state that I meet the above qualifications for exemption and am therefore exempt
from filing financial disclosure statements.
Candidate Signature Date
Witness Signature D to -
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.
OCR 11 101