CANDIDATE / OFFICEHOLDER CAMPAIGN FINANCE REPORT
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1 CANDIDATE / OFFICEHOLDER CAMPAIGN FINANCE REPORT The C/OH Instruction Guide explains how to complete this form. 3 C A N D I D A T E / O F F I C E H O L D E R N A M E M S / M R S / M R L A S T FORM C/OH COVER SHEET PG 1 a 1 Filer ID (^hics C^jmrijission Filers) 2 Tota^pages filed: S U F F I X OFFICE USE ONLY Received 4 C A N D I D A T E / O F F I C E H O L D E R M A I L I N G A D D R E S S A D D R E S S / PO BOX; A P T / S U I T E i CiTY; S T A T E ; ZIP C O D E I I Change of Address 5 C A N D I D A T E / O F F I C E H O L D E R P H O N E A R E A C O D E P H O N E N U M B E R Hand-deiivered or Postmarked 6 C A M P A I G N T R E A S U R E R N A M E M S / M R S / MR Receipt # Amount 3 Processed N I C K N A M E L A S T S U F F I X imaged 7 C A M P A I G N T R E A S U R E R A D D R E S S S T R E E T A D D R E S S (NO P O B O X PLEASE); A P T / S U I T E #; CITY; S T A T E ; ZIP C O D E (Residence or Business) 8 C A M P A I G N T R E A S U R E R P H O N E A R E A C O D E P H O N E N U M B E R E X T E N S I O N (^/7) ^6-0/63 9 R E P O R T T Y P E I I January 15 30th day before election Runoff I I July 15 [ u ^ S t h day before election Exceeded $500 limit j I 15th day after campaign ' ' treasurer appointment (Officeholder Only) I I Final Report (Attach C/OH - FR) 10 P E R I O D C O V E R E D Month Day Year / J / THROUGH Month Day Year 11 E L E C T I O N E L E G T i O N D A T E E L E C T I O N T Y P E Month Day Year I I Primary j } Runoff ^ ^ ^ e n e r a l Special I I Other Description 12 O F F I C E O F F I C E HELD (if any) 13 O F F I C E S O U G H T (if known) GO TO PAGE 2 Forins provided by Texas Ethics Commission Revised 9/8/2015
2 CANDIDATE / OFFICEHOLDER CAMPAIGN FINANCE REPORT FORM C/OH COVER SHEET PG 2 14 C / O H N A M E 15 Filer ID (Ethics Commission Filers) 16 N O T I C E F R O M P O L I T I C A L C O M M I T T E E ( S ) i THIS BOX IS FOR NOTICE OF POLITICAL CONTRIBUTIONS ACCEPTED OR POUTICAL EXPENDITURES MADE BY POLITICAL COMMITTEES TO SUPPORT THE CANDIDATE / OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATE'S OR OFFICEHOLDER'S KNOWLEDGE OR CONSENT. CANDIDATES AND OFFICEHOLDERS ABE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY RECEIVE NOTICE OF SUCH EXPENDITURES. C O M M I T T E E T Y P E C O M M I T T E E N A M E 1 1 G E N E R A L 1 1 IsPECiFiC C O M M I T T E E A D D R E S S I C O M M I T T E E C A M P A I G N T R E A S U R E R N A M E 1 1 Additional Pages C O M M I T T E E C A M P A I G N T R E A S U R E R A D D R E S S 17 C O N T R I B U T I O N T O T A L S 1. TOTAL POLITICAL CONTRIBUTIONS OF $50 OR LESS (OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS), UNLESS ITEMIZED $ 2. TOTAL POLITICAL CONTRIBUTIONS (OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS) T O T A L S 3. TOTAL POLITICAL EXPENDITURES OF $100 OR LESS, UNLESS ITEMIZED $ 4. TOTAL POLITICAL EXPENDITURES ' ^ C O N T R I B U T I O N B A L A N C E O U T S T A N D I N G L O A N T O T A L S 5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY OF REPORTING PERIOD 6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE LAST DAY OF THE REPORTING PERIOD $ 18 A F F I D A V I T 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 under Title t&relection Code. AFFIX N O T A R Y S T A M P / S E A L A B O V E S w o r n t o a n d subscribed before m e, by the said day, of 7\-jr t I _ ^ 2 0 Cm\(^^njvp\rc\l ^ ^-^' ^ -^"^ h a n d a n d seal of office., Signature of officer administering oath Printed name of officer administering oath Title of officer adrninistering oath
3 S U B TOTALS = C / O H F ORM C/OH C O V E R S H E E T PG 3 19 FILER N A M E 20 Filer ID (Ethics Commission Filers) 21 S C H E D U L E S U B T O T A L S N A M E O F S C H E D U L E SUBTOTAL AMOUNT 1. S C H E D U L E A 1 : M O N E T A R Y POLITICAL C O N T R I B U T I O N S ' 1, ISO. oo 2. S C H E D U L E A2: N O N - M O N E T A R Y (IN-KIND) POLITICAL CONTRIBUTIONS $ 3. S C H E D U L E S : P L E D G E D C O N T R I B U T I O N S $ 4. S C H E D U L E E : L O A N S $ 5. S C H E D U L E F 1 : POLITICAL S M A D E F R O M POLITICAL C O N T R I B U T I O N S 6. S C H E D U L E F2: UNPAID I N C U R R E D OBLIGATIONS $ 7. S C H E D U L E F3: P U R C H A S E O F I N V E S T M E N T S M A D E F R O M POLITICAL C O N T R I B U T I O N S $ 8. S C H E D U L E F4: S M A D E B Y C R E D I T C A R D $ 9. S C H E D U L E G: POLITICAL S M A D E F R O M P E R S O N A L F U N D S $ 10. S C H E D U L E H: P A Y M E N T M A D E F R O M POLITICAL C O N T R I B U T I O N S T O A B U S I N E S S O F C/OH $ 11. S C H E D U L E 1: NON-POLITICAL S M A D E F R O M POLITICAL C O N T R I B U T I O N S $ 12. S C H E D U L E K: INTEREST, C R E D I T S, GAINS, R E F U N D S, A N D C O N T R I B U T I O N S $ R E T U R N E D T O FILER
4 M O N E T A R Y P O L I T I C A L CONTRIBUTIONS SCHEDULE A 1 The Instruction Guide explains h o w to complete this form. 1 Total pages Schedule A1: ^ 2 FILER N A M E. ^ 3 Filer ID (Ethics Commission Filers) 5 Full name of contributor f l out-of-state PAG (ID#: l Si// Cdfi/rrei^ 6 7 Amount of contribution ($) 8 Principal occupation / Job title (See Instructions) 9 Employer (See Instructions) Full name of contributor n out-of-state PAG (ID#: ) (OS Uo^Clecf ill Vt ujeam^t^f^ 70^ Amount of contribution ($) * 100,00 Full name of contributor j "! out-of-state PAG ( I D * 1 Amount of contribution ($) ^5CO. 00 Full name of contributor n out-of-state PAC (IDS: ) /^. 3~. &ri^^ A..'iA^ Amount of contribution ($) ^/OO. &0 Principal occupationv Job title (See Instructions) Employer (See Instructions) ATTACH ADDmONAL COPIES OF THIS SCHEDULE AS NEEDED If contributor Is out-of-state PAC, please see Instruction guide for additional reporting requirements. Forms provided by Texas Ethics Commission Revised 9/8/2015
5 M O N E T A R Y P O L I T I C A L C O N T R I B U T I O N S SCHEDULE A 1 The Instruction Guide explains how to complete this form. 1 Total pages Schedule A 1 : ^ 2 FILER N A M E. r"' 3 Filer ID (Ethics Commission Filers) 4 5 Full name of contributor f l out-of-state PAC (ID#: ) 7 Amount of contribution ($) S ^ /S'D. Oo 8 Principal occupation / Job title (See Instructions) 9 Employer (See Instructions) Full name of contributor f l out-of-state PAC nd#: 1 Amount of contribution ($) Contributor address; City; State, Zip Code Principal occugation / Job title (See Instructions) Employer (See Instructions) Full name of contributor out-of-state PAG (ID#: ) Amount of contribution ($) Full name of contributor n out-of-state PAG (ID#: 1 Amount of contribution ($) ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED If contributor Is out-of-state PAC, please see instruction guide for additional reporting requirements.
6 P O L I T I C A L S M A D E FROM P O L I T I C A L C O N T R I B U T I O N S SCHEDULE F 1 EXPENDITURE CATEGORIES FOR BOX 8(a) A d v e r t i s i n g E x p e n s e E v e n t E x p e n s e L o a n R e p a y m e n t / R e i m b u r s e m e n t Solloitation/Fundraising E x p e n s e Accountrng«anking F e e s Office Overhead/Rental E x p e n s e Transportation E q u i p m e n t s Related E x p e n s e Consulting E x p e n s e Food/Beverage E x p e n s e Polling E x p e n s e T r a v e l In District C o n t n b u t i o n s / D o n a t i o n s M a d e B y Gift/Awards/Memorials E x p e n s e Printing E x p e n s e T r a v e l O u t O f District Gandidate/Officeholder/Political C o m m i t t e e Legal Services SalariesAWages/Contraot Labor o t h e r (enter a category not listed above) Credit Card Payment The Instruction Guide explains how to complete this form. 1 Total pages Schedule F1 2 FILER N A M E _ 3 Filer ID (Ethics Commission Filers) / 4 5 Payee name / ^ ' A St 6 Amount ($) 7 Payee address; <^ity; State; Zip Code "Zoo Sa^^u<4zL^ s (a) Category (See Categories listed at the top of this schedule) (b) Description P U R P O S E OF 1 1 Check if travel outside of Texas. Complete Schedule T. 1 \ Check if Austin, T X, officeholder living expense 9 Complete ONLY if direct Candidate / Officeholder name Office sought Office held expenditure to benefit C/OH Payee name Amount ($) /2-7. IS Payee address; City; State; Zip Code Category (See Categories listed at the top of this schedule) Description P U R P O S E OF 1 1 Check if travel outside of Texas. Complete Schedule T. f 1 Check if Austin, T X, officeholder living expense Complete ONLY if direct Candidate / Officeholder name Office souaht Office held expenditure to benefit C/OH Payee name Amount ($) Payee address; City; State; Zip Code Category (See Categories listed at the top of this schedule) Description P U R P O S E OF 1 1 Check if travel outside of Texas. Complete Schedule I 1 1 Check if Austin, TX, officeholder living expense Complete ONLY if direct Candidate / Officeholder name Office sought Office held expenditure to benefit C/OH ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
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