CANDIDATE
/
OFFICEHOLDER
FORM
C/OH
CAMPAIGN
FINANCE
REPORT
COVER
SHEET
PG
2
14
C/OH
(Ethics Commission Filers)
16
NOTICE
FROM
THIS
lOX
IS FOR NOTICE
OF
POLmCAL CONTRIIIITIONS
ACCEPTED
OR
POLmCAL
EXPENDITURES MADE
IV
POLITlCAl
COMMITTEES
TO
POLITICAL
SUPPORT THE
CAIIOIOATE;
I OFFICEHOLDER. THESE EXPENDITURES &lAY HAVE
8EEN
MADE WfTHOUT
THE
CANDIDATE'S OR OFFICEHOLDER'S
COMM/TTEE(S)
KNOWLEDGE
OR CONSENT. CAHOIDATES
ANO
OFFICEHOLDERS
ARE
ReQUIRED
TO
REPORT THIS INFOR&lATIOII
ONLY
IF
THE~
RECEIVE
1I0llCE
OF
SUCH EXPENDITURES.
OSPECIFIC
17
Addilional Pages
TOTALS
EXPENDITURE
TOTALS
CONTRIBUTION
BALANCE
OUTSTANDING
LOAN
TOTALS
18
AFFIDAVIT
COMMITTEE CAMPAIGN TREASURER
NAME
-_._._-_.
__
._
..
_---------
COMMITTEE
CAMPAIGN
TREASURER ADDRESS
I swear,
or
affirm, under penalty
of
perjury, that the accompanying report is
true and correct and includes
all information required to be reported
by
me
":Z0~'
-
~ch12<.~
AFFIX
NOTARY
STAMP
I
SEALABOVE
,
to
certify
which,
witness
my
hand
and
seal
of
office
.
.
--T-------
/&:dte)/
bel..
Printed
name
of
officer
administering
oath
Forms provided by Texas Ethics Commission
www.elhics.state.tX.U5
-,..-_
.............
__
..
_--
TOTAL POLITICAL
CONTRIBUTIONS
OF $50 OR LESS (OTHER THAN
PLEDGES.
LOANS.
OR GUARANTEES OF LOANS), UNLESS ITEMIZED
$
0-
f-------------------~-.---__t-----.--
....
-
TOTAL
POLITICAL
CONTRIBUTIONS
(OTHER THAN PLEDGES, LOANS. OR GUARANTEES OF LOANS)
$
TOTAL POLITICAL EXPENDITURES
OF
$100
OR LESS.
ITEMIZED
$ -
0-
f.------------·---------------i-·--·-·---
POLITICAL
EXPENDITURES
$
J----.----~.-------------
..
----
..
-
..
-,------
..
-.-.-
6.
POLITICAL
CONTRIBUTIONS
MAINTAINED
AS
OF THE
LAST
DAY
Of"\CT''''·!
PERIOD
TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
LAST
DAY OF THE REPORTING PERIOD
$
-0
$ - 0
Signature
of
Candidate
or
Officeholder
tt----
•
this
the
ift--_
(
Revised
9/8/2015
