Hurst, Terry
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 u ntil 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: 2. Name of Candidate or Committee: 3. Candidate e-mail address:
4. ampai n Ad ress and hone: City State Zip Code Phone
322 J.3 S,_
5. Home Address and Phone (if different than item 4 above): City State Zip Code Phone
6. Office Sought (include district number, if applicable) 7. Party Affliation 8. Election Year
7
9. Treasure Name: 10. Treasurer e-mail address:
11. Treasurer Address and Phone: City State Zip Code Phone
/~21 I Icl, 121 1),Z14 i' 4,; /ice f 517,71
12. Candidate and Treasurer Signature (both signatures must be witnessed. Treasurercan not witness candidate's signature):
ignature 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 5 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:
Candidate's Name:
Candidate's Position: e6ai"a ~ S lr~
Residential Address: IA Z O /_/~/C_x leG-
City: 11,/ I)t;l t1, //e State: TN Zip:
I hereby state that I meet the above qualifications for exemption and am
therefore exempt from filing financial disclosure statements.
j
Candidate's Signature Date
Z?-
ness's ignature 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.
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