2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE CITY OF SAN MARCOS SPECIAL ELECTION BALLOT
TO: City Secretary/Secretary of Board
I request that my name be placed on the above-named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT (Include any place number or other distinguishing number, if any.) INDICATE TERM
FULL
UNEXPIRED
FULL NAME (First, Middle, Last) PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
1
PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural
Route. If you do not have a residence address, describe the address
at which you receive personal mail and location of residence.)
PUBLIC MAILING ADDRESS (Campaign mailing address, if available.)
CITY STATE ZIP CITY STATE ZIP
PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH
/ /
VOTER REGISTRATION VUID
NUMBER (Optional)
2
TELEPHONE CONTACT INFORMATION (Optional)
Home:
Work:
Cell:
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
IN STATE
__ ___ year (s)
_____ month(s)
IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
3
_____ year (s)
_____ month(s)
If using a nickname as part of your name to appear on the ballot, you are also signing and swearing to the following statements: I further swear
that my nickname does not constitute a slogan nor does it indicate a political, economic, social, or religious view or affiliation. I have been
commonly known by this nickname for at least three years prior to this election.
__________________________________Before me, the undersigned authority, on this day personally appeared (name) ___, who being by me
here and now duly sworn, upon oath says:
“I, (name) _____________________________________ __ ____, of ____________________________________ County, Texas, being a
candidate for the office of ___________________________________ ____ ____, swear that I will support and defend the Constitution and laws
of the United States and of the State of Texas. I am a citizen of the United States eligible to hold such office under the constitution and laws of
this state. I have not been finally convicted of a felony for which I have not been pardoned or had my full rights of citizenship restored by other
official action. I have not been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or
partially mentally incapacitated without the right to vote. I am aware of the nepotism law, Chapter 573, Government Code.
I further swear that the foregoing statements included in my application are in all things true and correct.”
X _____________________
SIGNATURE OF CANDIDATE
Sworn to and subscribed before me at ___________________, this the ______ day of __________, _______________.
SEAL
___________________________________________ ___
Signature of Officer Administering Oath
4
___________________________________
Title of Officer Administering Oath
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007) ______________________
Date Received
____________________________________________ ___
Signature of Secretary
Voter Registration Status Verified
2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
10/2016
INSTRUCTIONS
An application to have the name of a candidate placed on the ballot for any general election may not be filed earlier than 30 days
before the deadline prescribed by this code for filing the application. An application filed before that day is void. All fields must be
completed unless specifically marked optional.
The general election filing deadline is 5:00 p.m. 78 days prior to election day for any uniform election date.
If you have questions about the application, please contact the Secretary of State’s Elections Division at 800-252-8683.
NEPOTISM LAW
The candidate must sign this statement indicating his awareness of the nepotism law. The nepotism prohibitions of chapter 573,
Government Code, are summarized below:
No officer may appoint, or vote for or confirm the appointment or employment of any person related within the second degree
by affinity (marriage) or the third degree by consanguinity (blood) to himself, or to any other member of the governing body or
court on which he serves when the compensation of that person is to be paid out of public funds or fees of office. However,
nothing in the law prevents the appointment, voting for, or confirmation of anyone who has been continuously employed in the
office or employment for the following period prior to the election or appointment of the officer or member related to the
employee in the prohibited degree: six months, if the officer or member is elected at the general election for state and county
officers.
No candidate may take action to influence an employee of the office to which the candidate is seeking election or an employee or
officer of the governmental body to which the candidate is seeking election regarding the appointment or employment of a
person related to the candidate in a prohibited degree as noted above. This prohibition does not apply to a candidate’s actions
with respect to a bona fide class or category of employees or prospective employees.
Examples of relatives within the third degree of consanguinity are as follows:
(1) First degree: parent, child;
(2) Second degree: brother, sister, grandparent, grandchild;
(3) Third degree: great-grandparent, great-grandchild, uncle, aunt, nephew, niece.
These include relatives by blood, half-blood, and legal adoption. Examples of relatives within the second degree of affinity are as
follows:
(1) First degree: spouse, spouse’s parent, son-in-law, daughter-in-law;
(2) Second degree: brother’s spouse, sister’s spouse, spouse’s brother, spouse’s sister, spouse’s grandparent.
Persons related by affinity (marriage) include spouses of relatives by consanguinity, and, if married, the spouse and the spouse’s
relatives by consanguinity. These examples are not all inclusive.
FOOTNOTES
1
For rules concerning the form of a candidate’s name or nickname on the ballot, see Subchapter B, Chapter 52 of the Texas
Election Code.
http://www.sos.state.tx.us/elections/laws/hb484-faq.shtml
2
Inclusion of a candidate’s VUID is optional. However, many candidates are required to be registered voters in the territory from
which the office is elected at the time of the filing deadline. Please visit the Elections Division of the Secretary of State’s website
for additional information.
3
This refers to the length of residence inside the district or territory from which the office is elected. For example, length of
residence in a school district, for a school trustee office elected at large. This field MUST BE COMPLETED.
4
All oaths, affidavits, or affirmations made within this State may be administered and a certificate of the fact given by a judge,
clerk, or commissioner of any court of record, a notary public, a justice of the peace, city secretary (for a city office), and the
Secretary of State of Texas.
2-21
Prescrito por el Secretario de Estado
Sección 141.031, Capítulos 143 y 144, Código Electoral de Texas
1/2017
DEBE PROPORCIONARSE LA INFORMACIÓN REQUERIDA A MENOS QUE SE INDIQUE QUE ES OPCIONAL
SOLICITUD PARA FIGURAR EN LA BOLETA DE CITY OF SAN MARCOS ELECCN GENERAL A:
Secretario(a) de la Ciudad/ Secretario del Consejo
Solicito que mi nombre figure en la boleta oficial indicada más arriba como candidato/a al cargo a continuación.
PUESTO OFICIAL SOLICITADO (Incluya cualquier número de cargo u otro número distintivo, si el cargo lo
tiene.)
INDIQUE TÉRMINO
TÉRMINO COMPLETO
RMINO INCOMPLETO
NOMBRE COMPLETO (Primer nombre, segundo nombre, apellido) ESCRIBA SU NOMBRE COMO DESEA QUE FIGURE EN LA BOLETA¹
DIRECCIÓN RESIDENCIAL PERMANENTE (No incluya una casilla postal
o
u
na ruta rural. Si usted no tiene una dirección residencial, describa
el lugar en que recibe correspondencia personal y la ubicación de su
residencia.)
DIRECCIÓN POSTAL BLICA (Dirección en la que recibi
correspondencia relacionada a su campaña, si es disponible.)
CIUDAD ESTADO DIGO POSTAL CIUDAD ESTADO DIGO POSTAL
CORREO ELECTRÓNICO PÚBLICO (Si está
disponible.)
EMPLEO (No deje este espacio en
blanco.)
FECHA DE NACIMIENTO
/ /
V
UID – NÚMERO UNICO DE
IDENTIFICACION DE
VOTANTE (Opcional)²
INFORMACIÓN DE CONTACTO (Opcional)
Tel. residencial:
Tel. laboral:
Tel. celular:
DURACIÓN DE RESIDENCIA CONTINUA AL MOMENTO DE JURAMENTAR ESTA
SOLICITUD
EN EL ESTADO
__ ___ año(s)
_____ mes(es)
EN EL TERRITORIO POR EL
CUAL SERIA ELECTO/A³
_____ año(s)
_____ mes(es)
En caso de usar un apodo como parte de su nombre en la boleta, usted también firma y jura lo siguiente: Asimismo, juro que mi apodo no
constituye un lema político ni tampoco es una indicación de mis creencias o afiliaciones políticas, económicas, sociales o religiosas. Se me ha
conocido por este apodo durante al menos tres años antes de esta elección.
Ante mí, la autoridad suscrita, compareció (nombre)_ _________________________________ ___, quien frente a mí y bajo juramento debido,
declara:
“Yo, (nombre)___________________________________________, del condado de ____________________________________, Texas, siendo
candidato para el cargo oficial de _ _________________________________________ _, juro solemnemente que apoyaré y defenderé la
Constitución y las leyes de los Estados Unidos y del Estado de Texas. Soy ciudadano de los Estados Unidos elegible para ocupar tal cargo oficial
bajo la Constitución y las leyes de este Estado. No se me ha condenado por un delito mayor por el cual no haya sido absuelto o por el cual no se
me hayan restituido enteramente mis derechos de ciudadanía por medio de otra acción oficial. No existe un fallo final de un tribunal
testamentario que me declare total o parcialmente incapacitado mentalmente sin derecho a votar. Yo tengo conocimiento de la ley sobre el
nepotismo según el Capítulo 573 del Código de Gobierno.
Además, juro que las declaraciones anteriores que incluyo en mi solicitud son verdaderas y correctas”.
X _ ____________________
FIRMA DEL CANDIDATO
Jurado y suscrito ante en __ _______________ __, este día ______ de _ _______ __, _ ___________ ___.
SELLO
___________________________________________ ___
Firma del oficial que administra el juramento
________________________________ ___
Título del oficial que administra el juramento
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007) ___________________ ___
Date Received
____________________________________________ ___
Signature of Secretary
Voter Registration Status Verified
2-21
Prescrito por el Secretario de Estado
Sección 141.031, Capítulos 143 y 144, Código Electoral de Texas
10/2016
INSTRUCCIONES
La solicitud para que el nombre de un candidato figure en la boleta para cualquier elección general no deberá registrarse antes de los
treinta (30) as previos a la fecha límite para registrar la solicitud, según lo prescribe este código. Cualquier solicitud registrada antes
de esa fecha se declara inválida. Todos los campos deben ser completados a menos que se indique específicamente marcados como
opcional.
El último día para registrarse es a las 5 de la tarde setenta y ocho (78) días antes del día de la elección en el caso de elecciones
uniformes.
Si tiene alguna pregunta sobre la solicitud, por favor póngase en contacto con la división de elecciones del Secretario de Estado al 800-
252-8683.
LEY SOBRE EL NEPOTISMO
El candidato deberá firmar esta declaración para indicar que tiene conocimiento sobre la ley sobre el nepotismo. A continuación figuran
las prohibiciones del nepotismo según el capítulo 573 de Código Gobierno:
Ningún funcionario podrá nombrar, votar por o confirmar el nombramiento o empleo de ninguno de sus parientes en segundo grado
por afinidad (matrimonio) o en tercer grado por consanguinidad (sangre), o de los parientes de cualquier otro integrante del cuerpo
directivo o tribunal en que el funcionario celebre sesión cuando la compensación para esa persona se pagare con fondos públicos u
honorarios de su puesto oficial. Sin embargo, la ley no prohíbe el nombramiento, el votar por o la confirmación de ninguna persona que
haya trabajado en la oficina de manera continua o el empleo para el siguiente período antes de la elección o el nombramiento del
funcionario o miembro emparentado con el empleado en el grado prohibido: seis meses, si el funcionario o miembro se elige en una
elección general de funcionarios de estado y condado.
Ningún candidato podrá influir sobre un empleado relacionado al puesto oficial al cual el candidato aspira o un empleado o funcionario
del cuerpo fiscal al cual el candidato aspira respecto del nombramiento o el empleo de un pariente del candidato en un grado prohibido
según se indica arriba. Esta restricción no se dirige a las acciones de un candidato respecto de una clase o categoría de empleados o
posibles empleados de buena fe.
Los ejemplos de parentesco en tercer grado por consanguinidad son los siguientes:
(1) Primer grado: padre, madre, hijo(a);
(2) Segundo grado: hermano(a), abuelo(a), nieto(a);
(3) Tercer grado: bisabuelo(a), bisnieto(a), tío(a), sobrino(a).
Los siguientes incluyen parentescos de consanguinidad, medios hermanos y adopción legal. Los ejemplos de parentescos en segundo
grado por afinidad son los siguientes:
(1) Primer grado: cónyuge, suegro(a), yerno, nuera;
(2) Segundo grado: cuñado(a), abuelo(a) del cónyuge.
Las personas que están emparentadas por afinidad (matrimonio) incluyen los cónyuges de parientes emparentados por consanguinidad,
y, si casados, el cónyuge y los parientes del cónyuge por consanguinidad. No todos estos ejemplos son inclusivos.
NOTAS
¹Para reglas sobre la forma del nombre de un candidato o apodo en la boleta electoral, vea el subcapítulo B, Capítulo 52 del Código
Electoral de Texas.
http://www.sos.state.tx.us/elections/laws/hb484-faq.shtml
²
La inclusión del número único de identificación de votante (VUID, por sus siglas en Ingles) es opcional. Sin embargo, para muchos
candidatos, es un requisito estar registrados como votantes en el territorio por el cual serían electos a partir de la fecha límite de la
solicitud. Puede encontrar información adicional sobre el requisito de registro de votante en nuestra
página:
³Esto se refiere a la duración de la residencia dentro del distrito o territorio de que se elige la oficina. Por ejemplo, la duración de
residencia en un distrito escolar, para una oficina del consejero escolar elegida en general. Este campo DEBE SER COMPLETADO.
⁴Los juramentos, las declaraciones juradas o las afirmaciones que se efectúen dentro de este Estado podrán ser administradas por un
juez, escribano o comisionado de alguna corte de registro, por un notario público, un juez de paz, un secretario de la ciudad o el
Secretario de Estado de Texas, quienes cuentan con la capacidad de proporcionar un certificado del hecho.
Revised 12/7/2017
Forms provided by Texas Ethics Commission
www.ethics.state.tx.us
APPOINTMENT OF A CAMPAIGN TREASURER
BY A CANDIDATE
FORM
CTA
PG
1
3
8
9
2
AREA CODE PHONE NUMBER EXTENSION
MS / MRS / MR FIRST MI
OFFICE USE ONLY
6
5
ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE
STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; ZIP CODE
()
GO TO PAGE 2
Signature of Candidate
I am aware of my responsibility to file timely reports as required by title 15 of
the Election Code.
I am aware of the restrictions in title 15 of the Election Code on contributions
from corporations and labor organizations.
10
7
MS/MRS/MR FIRST MI NICKNAME LAST SUFFIX
See CTA Instruction Guide for detailed instructions.
Date Processed
1
Total pages filed:
CAMPAIGN
TREASURER
NAME
CANDIDATE
MAILING
ADDRESS
CANDIDATE
NAME
CAMPAIGN
TREASURER
STREET
ADDRESS
CAMPAIGN
TREASURER
PHONE
CANDIDATE
SIGNATURE
I am aware of the Nepotism Law, Chapter 573 of the Texas Government Code.
NICKNAME LAST SUFFIX
Filer ID #
Date Imaged
4
AREA CODE PHONE NUMBER EXTENSION
()
CANDIDATE
PHONE
Date Hand-delivered or Postmarked
Date Received
Date Signed
(residence or business)
OFFICE
SOUGHT
(if known)
OFFICE
HELD
(if any)
Receipt #
Amount $
Revised 12/7/2017
Forms provided by Texas Ethics Commission
www.ethics.state.tx.us
CANDIDATE MODIFIED
REPORTING DECLARATION
FORM
CTA
PG
2
This appointment is effective on the date it is filed with the appropriate filing authority.
11 CANDIDATE
NAME
Signature of Candidate
MODIFIED
REPORTING
DECLARATION
Year of election(s) or election cycle to
which declaration applies
I do not intend to accept more than $500 in political contributions or
make more than $500 in political expenditures (excluding filing fees)
in connection with any future election within the election cycle.
I understand that if either one of those limits is exceeded, I will be
required to file pre-election reports and, if necessary, a runoff
report.
•• This declaration must be filed no later than the 30th day before
the first election to which the declaration applies. ••
COMPLETE THIS SECTION ONLY IF YOU ARE
CHOOSING MODIFIED REPORTING
•• The modified reporting option is valid for one election cycle only. ••
(An election cycle includes a primary election, a general election, and any related runoffs.)
12
•• Candidates for the office of state chair of a political party
may NOT choose modified reporting. ••
TEC Filers may send this form to the TEC electronically at treasappoint@ethics.state.tx.us or
Fax this form to (512) 463-8808 or mail to
Texas Ethics Commission
P.O. Box 12070
Austin, TX 78711-2070
Non-TEC Filers must file this form with the local filing authority
DO NOT SEND TO TEC
For more information about where to file go to:
https://www.ethics.state.tx.us/whatsnew/NewFilersGettingStarted.html
Revised 11/23/2010
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989)
www.ethics.state.tx.us
Date Received
Date Processed
CODE OF FAIR CAMPAIGN
PRACTICES
FORM
CFCP
C
OVER
S
HEET
Date Imaged
Pursuant to chapter 258 of the Election Code, every candidate and
political committee is encouraged to subscribe to the Code of Fair
Campaign Practices. The Code may be filed with the proper filing
authority upon submission of a campaign treasurer appointment
form. Candidates or political committees that already have a
current campaign treasurer appointment on file as of September 1,
1997, may subscribe to the code at any time.
Subscription to the Code of Fair Campaign Practices is voluntary.
TYPE OF FILER
ACCOUNT NUMBER
(Ethics Commission Filers)
2
1
3
NAME OF CANDIDATE
(PLEASE TYPE OR PRINT)
NAME OF COMMITTEE
(PLEASE TYPE OR PRINT)
GO TO PAGE 2
TITLE (Dr., Mr., Ms., etc.) FIRST MI
NICKNAME LAST SUFFIX (SR., JR., III, etc.)
NAME OF CAMPAIGN
TREASURER
(PLEASE TYPE OR PRINT)
OFFICE USE ONLY
CANDIDATE
If filing as a candidate, complete boxes 3 - 6,
then read and sign page 2.
POLITICAL COMMITTEE
If filing for a political committee, complete
boxes 7 and 8, then read and sign page 2.
4
TELEPHONE NUMBER
OF CANDIDATE
(PLEASE TYPE OR PRINT)
AREA CODE PHONE NUMBER EXTENSION
( )
5
ADDRESS OF CANDIDATE
(PLEASE TYPE OR PRINT)
STREET / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE
6
OFFICE SOUGHT
BY CANDIDATE
(PLEASE TYPE OR PRINT)
7
8
TITLE (Dr., Mr., Ms., etc.) FIRST MI
NICKNAME LAST SUFFIX (SR., JR., III, etc.)
Date Hand-delivered or Postmarked
Revised 11/23/2010
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989)
www.ethics.state.tx.us
CODE OF FAIR CAMPAIGN PRACTICES
There are basic principles of decency, honesty, and fair play that every candidate and political committee in this state
has a moral obligation to observe and uphold, in order that, after vigorously contested but fairly conducted campaigns,
our citizens may exercise their constitutional rights to a free and untrammeled choice and the will of the people may be
fully and clearly expressed on the issues.
THEREFORE:
(1) I will conduct the campaign openly and publicly and limit attacks on my opponent to legitimate challenges to my
opponent’s record and stated positions on issues.
(2) I will not use or permit the use of character defamation, whispering campaigns, libel, slander, or scurrilous attacks
on any candidate or the candidate’s personal or family life.
(3) I will not use or permit any appeal to negative prejudice based on race, sex, religion, or national origin.
(4) I will not use campaign material of any sort that misrepresents, distorts, or otherwise falsifies the facts, nor will I
use malicious or unfounded accusations that aim at creating or exploiting doubts, without justification, as to the
personal integrity or patriotism of my opponent.
(5) I will not undertake or condone any dishonest or unethical practice that tends to corrupt or undermine our system
of free elections or that hampers or prevents the full and free expression of the will of the voters, including any
activity aimed at intimidating voters or discouraging them from voting.
(6) I will defend and uphold the right of every qualified voter to full and equal participation in the electoral process,
and will not engage in any activity aimed at intimidating voters or discouraging them from voting.
(7) I will immediately and publicly repudiate methods and tactics that may come from others that I have pledged not
to use or condone. I shall take firm action against any subordinate who violates any provision of this code or the
laws governing elections.
I, the undersigned, candidate for election to public office in the State of Texas or campaign treasurer of a political
committee, hereby voluntarily endorse, subscribe to, and solemnly pledge myself to conduct the campaign in accordance
with the above principles and practices.
Date
Signature
City of San Marcos
City Council/Council Appointee/P&Z Commissioner
Annual Financial Disclosure Form
NOTES
1. This report covers the reporting period from:
2. Do not leave items blank. If item is not applicable, mark NA or NONE.
3. Attach information on additional pages, if necessary.
Name:
Residence address:
Title of position held with the City:
Name of spouse: NA or NONE
Names of all dependent children: NA or NONE
Names under which you, your spouse, or any of your dependent children do business: NA or NONE
1.
2.
3.
NOTE – You may use the following reporting categories to describe amounts and values:
1. Identify each source of income amounting to more than $100.00 received in the reporting period by
you, your spouse, or any of your dependent children: NA or NONE
Name & full address of income source
Nature of income
[e.g., salary, dividends,
rent, etc.]
Amount of income
[by reporting category]
Income of
[e.g., self, spouse,
or dependent child]
Category I At least $100.00 but less than $10,000.00
Category II
At least $10,000.00 but less than $20,000.00
Category III At least $20,000.00 but less than $50,000.00
Category IV At least $50,000.00 but less than $75,000.00
Category V At least $75,000.00 but less than $100,000.00
Category VI $100,000.00 or more MUST report to nearest $100,000.00
(For example: $125,000 would be reported to $100,000)
2. Identify each option held, owned, acquired or sold by you, your spouse, or any of your dependent
children during the reporting period: NA or NONE
Nature of option
[real estate, stock, etc.]
Amount of transaction
[by reporting category]
Name & full address of other parties
to the transaction
3. Identify each business entity, nonprofit entity or union in which you, your spouse, or any of your
dependent children was a partner, manager, officer, member of the board of directors, proprietor or
beneficiary during the reporting period: NA or NONE
Name & full address of business or nonprofit entity or union
Position held
4. Identify each business entity, nonprofit entity or union in which you, your spouse, or any of your
dependent children had an ownership interest with a fair market value of more than $100.00 at any time
during the reporting period: NA or NONE
Name & full address of business
or nonprofit entity or union
Description of ownership
interest [e.g., owner,
partner, stockholder]
Value of
ownership
interest
[by reporting
category]
Number of
shares
held/shares
issued
[if applicable]
Net gain or
loss from
sale of stock
[by reporting
category]
5. Identify any real property in the City or ETJ in which you, your spouse, or any of your dependent children
had an interest as owner, beneficial owner (holder of a mortgage), business owner (partner in a partnership;
or board member, officer or owner of more than 5% of stock of a corporation), or a leaseholder:
NA or NONE
Full address or legal
description
Name & full address
of owner(s)
[if other than you, your
spouse or children]
Fair market value
[by reporting category]
and present use
For leased
property, annual
rental amount
[by reporting
category]
Homestead
exemption
on this
property?
6. Identify persons, business entities or guarantors to whom you, your spouse, or any of your dependent
children owed a debt of more than $100.00 during the reporting period (not including debts owed to persons
related within the second degree of consanguinity or affinity, or loans to a political campaign which were
reported as required by law): NA or NONE
Name & full address of person, business entity or
guarantor to which debt was owed
Amount of debt
[by reporting category]
Amount of repayment
during reporting period
[by reporting category]
7. Provided this information is not privileged by law, identify persons, business entities or guarantors who
owed you, your spouse, or any of your dependent children a debt of more than $100.00 during the reporting
period (not including debts owed by persons related within the second degree of consanguinity or affinity:
NA or NONE
Name & full address of person, business entity or
guarantor that owed the debt
Amount of debt
[by reporting category]
Amount of repayment
during reporting period
[by reporting category]
Name & full address of person, business entity or
guarantor that owed the debt
Amount of debt
[by reporting category]
Amount of repayment
during reporting period
[by reporting category]
8. Identify the source of each gift or accumulation of gifts from one source of more than $100.00 in value
received during the reporting period by you, your spouse, or any of your dependent children, or received
by another person for the use and benefit of you, your spouse, or any of your dependent children (not
including (1) a gift received from a relative if given because of kinship, or (2) a gift received by will, by
intestate succession or as distribution from an inter vivos or testamentary trust established by a spouse or
ancestor): NA or NONE
Name & full address of source of gift(s)
Description of gift(s)
Amount or value of gift(s)
[by reporting category]
9. Provided this information is not privileged by law, if you were the owner of 5% or more of any business
entity during the reporting period, list all customers from whom the entity received at least 10% of its gross
income during the reporting period: NA or NONE
Name & full address of customer
10. Identify any financial interest in any franchisee of the City held during the reporting period by you,
your spouse, or any of your dependent children [note: franchise holders are A)Time Warner Cable, B)
Pedernales Electric Cooperative, C) Bluebonnet Electric Cooperative, and D) CenterPoint Energy Entex]:
NA or NONE
Name of franchise holder
Description of financial interest held
[stock, mortgage, note etc.]
Value of financial interest
[by reporting category]
11. Identify any transaction during the reporting period by you, your spouse, or any of your dependent
children with any holder of any franchise issued by the City, other than as a customer or patron:
NA or NONE
Name of franchise holder
Description of transaction
Value of transaction
[by reporting category]
AF
FIDAVIT I swear under penalty of perjury that the above statement is true and correct. I acknowledge that the
disclosure applies to a family member (as defined by Section 176.001(2), Local Government Code) of this local
government officer. I also acknowledge that this statement covers the 12-month period described by Section
176.003(a), Local Government Code.
S
ignature of Local Government Officer/Appointed Official
AF
FIX NOTARY STAMP / SEAL ABOVE
S
worn to and subscribed before me, by the said , this the day of
, 20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
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