HomeMy WebLinkAboutStacey Kemp 011520147
8
9
Texas ethics Commission PO. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989) .. ,..:...--'---------------_---.:._-----_-..:'---=-----_....:....-_--_......:....--.:..,
CANDIDATE I OFFICEHOLDER FORM CIOH
CAMPAIGN FINANCE REPORT oOR GINALCoVER SHEET PG 1
ACCOUNT #
(Elhics Commission Filers) The e/OH Instruction Guide explains how to complete this form.
3 CANDIDATE 1
OFFICEHOLDER
NAME
4 CANDIDATE 1
OFFICEHOLDER
MAILING
ADDRESS
o change of address
5 CANDIDATEI
OFFICEHOLDER
PHONE
6 CAMPAIGN
TREASURER
NAME
CAMPAIGN
TREASURER
ADDRESS
(residence or business)
CAMPAIGN
TREASURER
PHONE
REPORT TYPE
MS/MRS/MR FIRST MI
.&1-(l~~
NICKNAME lAST SUFFIX
k'e..rn
ADDRESS f PO BOX; APT I SUITE #; CITY; STATE; ZIP CODE
~ 0 ,~O~-3Lfq ~ M~<:'i~Y\t~
r5011
AREA CODE PHONE NUMBER EXTENSION
MI
MSfMRS/MRC!lQ. J~ .
NICKNAME lAST SUFFIX
PJ s
2 Total pages filed:
Dale Imaged
/ -/3-/4
STREET ADDRESS (NO PO BOX PLEASE); APT I SUITE #; CITY; STATE; ZIP CODE
e. \ X 15
AREA CODE PHONE NUMBER EXTENSION
(ql~) 5·lQ~-gLjL/ D
~ January 15 o 30th day before election 0
o July 15 o 8th day before election o limit
10 PERIOD Mon'J1 Day Year
COVERED THROUGH
Runoff
o
o
DayMonth
Exceeded $500
ELECTION TYPE ELECTION DATE 11 ELECTION
~mary o Runoff o General o Special
12 OFFICE
www.ethics.state.tx.us Revised 04/19/2013
Month Day Year
GOTOPAGE2
Texoo Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
SUPPORT & TOTALS
TliIS BOX IS FOR NOTICE OF POUTICAL CONlRIBUTIONS ACCEPlED OR POUTICAL EXPENDITURES MADE BY POLITICAL COMMIITEES TO SUPPORT TliE
CANDIDATE 1 OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATE'S OR OFRCEHOLDER'S KNOWLEDGE OR
CONSENT. CANDIDATES AND OFFICEHOLDERS ARE. REQUIRED TO REPORT TliIS INFORMATION ONLY IF TliEY RECEIVE NOTICE OF SUCH EXPENDITURES.
CANDIDATE I OFFICEHOLDER REPORT: FORM C/OH
OR COVER SHEET PG 2
IGINA
16 NOTICE FROM
POLITICAL
COMMITTEE(S)
14 C/OH NAME
COMMITTEE NAME
COMMITTEE TYPE
D GENERAL
COMMITTEE ADDRESS
D SPECIFIC
COMMITTEE CAMPAIGN TREASURER NAME
o additional pages w
COMMITTEE CAMPAIGN TREASURER ADDRESS
17 CONTRIBUTION
TOTALS
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)
EXPENDITURE
TOTALS 3. TOTAL POLITICAL EXPENDITURES OF $100 OR LESS, UNLESS ITEMIZED $
4. TOTAL POLITICAL EXPENDITURES
o
$ 1~5D'~
CONTRIBUTION
BALANCE 5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY
OF REPORTING PERIOD $/00 ~
OUTSTANDING
LOAN TOTALS 6 TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
LAST DAY OF THE REPORTING PERIOD $
18 AFFIDAVIT
DEBOIAH KJV PIMA
NocIIy NItic
STA'IE OF TEXAS
My e-.&po "-'." '6
I swear, or affirm, under penalty of perjury, that the accompanying report
is true and correct and includes all information "equired to be reported by
r Title 15, Election Code.
seal of office.
AFFIX NOTARY STAMP I SEAL ABOVE
Sworn to and subscribed before me, by the said ---~-~~-l...(;:....Kt----t!..-t-L..L..!,+£-_--'this the
/8 of ee n IA ""'I' 20 ~day
www.ethicS.state.tx.us Revised 04/19/2013
Texas Ethics Commission P.O Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
(EthicS Commission Filers)
In-kind contribution
description (if applicable)
In-kind contribution
description (if applicable)
In-kind contribution
description (if applicable)
In-kind contribution
description (if applicable)
.......
L-5'
In-kind t<:antributioi
descriptio r aPl'lti ble
-. ,W
~
~ f,}
-.f:'" ~
POLITICAL CONTRIBUTIONS
SCHEDULE AOTHER THAN PLEDGES OR LOANS il ORIGINAL
The Instruction Guide explains how to complete this form.
1 Total pages Schedule A:
2 FILER NAME
0{tlttLj ~: tf'I
3 ACCOUNT #
4 Date 5 Full name of contributor o out-of-state PAC (ID#: ) 7 Amountof 18
.uJ-V h flJ),/la-ylocl
contribution ($) ,
10/ 10 I,;). 6 IContributor address; City; State; Zip Code
Jf75tJ ~ I150~ {<J. (jJ1jVeflS/'~1F /6/ IfY\ t.K..,' f) n e..L I IX 50u, q (If travel outside of Texas, complete Schedule T)
9 Principal occupation / Job title (See Ins{ructions)
1
10 Employer (See Instructions)
Date Full name of contributor [J out-aI-slate PAC (10#: ) Amount of I
contribution ($)
I
Contributor address; City; State; Zip Code I
I
I
(If travel outside of Texas. complete Schedule n
Principal occupation / Job title (See Instructions)
I
Employer (See Instructions)
Date Full name of contributor 0 out-of-state PAC (ID#: ) Amountof I
contribution ($) I
Contributor address; City; State; Zip Code I
I
I
(If travel outside of Texas, complete Schedule T)
Principal occupation / Job title (See Instructions)
I
Employer (See Instructions)
Date Full name of contributor o out-aI-state PAC (10#: ) Amount of I
contribution ($)
I
Contributor address; City; State; Zip Code I
I
I
(If travel outside of Texas, complete Schedule T)
Principal occupation / Job title (See Instructions)
I
Employer (See Instructions)
Date Full name of contributor o out-aI-state PAC (10It ) Amount of I
contribution ($) I
'. IContributor address; City; State; Zip Code
:
(If travel outside of Texas, comJ;;jfe Sch'~
Principal occupation / Job title (See Instructions)
I
Empioyer (See Instructions)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULEAS NEEDED
If contributor is out-of-state PAC, please see instruction guide foradditional reporting requirements.
www.ethics.state.tx.us Revised 04/19/2013
Tex8s-Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOD 1-800-735-2989)
PLEDGED CONTRIBUTIONS [) RIGINAl SCHEDULE B
1 Total pages Schedule B
The Instruction Guide explains how to complete this form.
3 ACCOUNT # (Ethics Commission Filers) 2 FILER NAME
4 ¢ ¢¢ ¢ ¢ ¢TOTAL OF UNITEMIZED PLEDGES: 1$
Amountof8 19 In-kind description
pledge ($)
5 Date 6 Full name of pledgor [J out-aI-slate PAC (100 )
(if applicable)
1
7 Pledgor address; City; State; Zip Code 1
1
1
(If travei outside of Texas, complete Schedule T)
10 Principal occupation I Job title (See Instructions) 11 Employer (See Instructions)
1
Full name of pledgor ) Amount of In-kind descriptionD out-ol-state PAC (100:Date I pledge ($) (if applicable)I
Pledgor address; City; State; Zip Code I
I
1
(If travel outside of Texas, complete Schedule T)
Principal occupation I Job title (See Instructions) Employer (See Instructions)
I
Date Amount of In-kind descriptionFull name of pledgor D out-aI-stale PAC (tOO: ) 1
pledge ($) (if applicable)
I
1Pledgor address; City; State; Zip Code
1
1
(If travel outside of Texas, complete Schedule T)
Principal occupation I Job title (See Instructions) Employer (See Instructions)
I
Date Amountof 1 In-kind description
pledge ($) (if applicable)
Full name of pledgor [J out-ol-state PAC (100. )
1
I
I
Pledgor address; City; State; Zip Code
1
(If travel outside of Texas, complete Schedule T)
Principal occupation I Job title (See Instructions) Employer (See Instructions) -... ,. ~
!iI r Ii
Date Amount of I In-kind daz:riPtien-.
pledge ($) (if appJic;;lble)
Full name of pledgor D out-ol-state PAC (10#: )
I W .
Pledgor address; City; State; Zip Code I -0 :rI
I rn ~
(If travel outside of Texas, complere-schedule T) i
Principal occupation I Job title (See Instructions) Employer (See Instructions)
1
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If contributor is out-of-state PAC, please see instruction guide for additional reporting requirements.
www.elhics.slale.lx.us Revised 04/19/2013
Texas'Ethics Commission PO Box 12070 Austin Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
LOANS DORIGI AL SCHEDULE E
1 Total pages Schedule E:
The Instruction Guide explains how to complete this torm.
2 FILER NAME 3 ACCOUNT # (Ethics Commission Filers)
4
TOTAL OF UNITEMIZED LOANS: q q q q q q $
5 Date of loan 7 Name of lender D out-aI-slate PAC (10/1: ) 9 Loan Amount ($)
6 Is lender 8 Lender address; City; State; Zip Code 10 Interest rate
a financial
Institution?
11 Maturity date
y N
12 Principal occupation I Job title (See Instructions) 13 Employer (See Instructions)
14 Description of Collateral 15 Check if personal funds were deposited into political account
Drcne 0
16 GUARANTOR 17 Name of guarantor 19 Amount Guaranteed ($)
INFORMATION
18 Guarantor address; City; State; Zip Code
D not applicable
20 Principal Occupation (See Instructions) 21 Employer (See Instructions)
Date of loan Name of lender D out-aI-stale PAC (10/1: ) Loan Amount ($)
Is lender Lender address; City; State; Zip Code Interest rate
a financial
Institution?
Maturity date
y N ......
Principal occupation I Job title (See Instructions) Employer (See Instructions) .. ~ ~.'
2: .-
Description of Collateral Check if personal funds were deposited into political acCOUnt 'W
0 none 0 -0 ~
GUARANTOR Name of guarantor Amount G~ant~ed('$) I
INFORMATION " -
Guarantor address; City; State; Zip Code
.&;
D not applicable
Principal Occupation (See Instructions) Employer (See Instructions)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
It lender is out-ot-state PAC, please see instruction guide tor additional reporting requirements.
www.ethics.state.tx.us Revised 04/19/2013
TexaS'Ethics Commission PO Box 12070 Austin Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
1POLITICAL EXPENDITURES SCHEDULE F ~'NAl
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Gift/Awards/Memorials Expense Salaries/Wages/Contract Labor Loan Repayment/Reimbursement
Accounting/Banking Legal Services Solicitation/Fundraising Expense Transportation Equipment & Related Expense
Consulting Expense Food/Beverage Expense Travel In District ContributionslDonations Made By
Event Expense Polling Expense Travel Out Of District Candidate/Officeholder/Political Committee
Fees Printing Expense Office Overhead/Rental Expense OTHER (enter a category not listed above)
The Instruction Guide explains how to complete this form.
2 3 ACCOUNT # (Ethics Commission Filers) 1 Total pages Schedule F: FILERSht ~
...... C-tA..A e (\'1 t~ 1
4 Date 5 payerrme (' ~1(It-q '~OJ3 Jnl1 ... Vl X)uY\fu ,eDl1hl,c}Q/l YClftu
6 Amount ($)
7 paYi~d~r~s; s~~rijCode'
I
cg /'15 r'\I)f1k ~ n nP-A 1 1'>( 150,()
8 PURPOSE (a) Category (See categories listed at the top of this schedule) (b) Description (II travel outside 01 Texas, complete Schedule T)
OF
EXPENDITURE ~e-e-s
9 Corrplete ~if direct Candidate / Officeholder name Office sought Office held
expenditure to benefit DOH
Date Payee name
Amount ($) Payee address; City; State; Zip Code
PURPOSE Category (See categories listed at the top of this schedule) Description (If travel outside of Texas, complete Schedule T)
OF
EXPENDITURE
Corrplete ()'IJLY if direct Candidate / Officeholder name Office sought Office held
expenditure to benefit DOH
Date Payee name
Amount ($) Payee address; City; State; Zip Code
PURPOSE Category (See catagories listed at the lop of this schedule) Description (If travel outside of Texas, comptete Schedule T)
OF
EXPENDITURE -.... ,~
Corrplete oo!..y if direct Candidate / Officeholder name Office sought Office~ld ~
expenditure to benefit DOH 5; '--
Date Payee name c...> J
"1:J ~
Amount ($) Payee address; City; State; Zip Code :::::J::
N..
., ~ J
-s:
PURPOSE Category (See categories listed at the top of this schedule) Description (If travel outside of Texas, complete Schedule T)
OF
EXPENDITURE
Complete ~ if direct Candidate / Officeholder name Office sought Office held
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
www.elhics.slale.lx.us Revised 04/19/2013
_. TexaS' Ethics Commission P.O Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989)
----, SCHEDULE GINAL
POLITICAL EXPENDITURES
MADE FROM PERSONAL FUNDS
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense GifUAwards/Memorials Expense
Accounting/Ban ki ng Lega I Services
Consulting Expense Food/Beverage Expense
Event Expense Polling Expense
Fees Printing Expense
The Instruction Guide explains how to complete this form.
1 Total pages Schedule G 2 FILER NAME
5 Payee name4 Date
6 Amount ($) 7 Payee address; City;
Reimbursement from
0 political contributions
intended
(a) Category (See calegories listed at the top of this schedule)8 PURPOSE
OF
EXPENDITURE
Payee nameDate
Amount ($) Payee address; City;
0 Reimbursement from
political contribullons
intended
Category (See categories listed at the top of this schedule)PURPOSE
OF
EXPENDITURE
Payee nameDate
Amount ($) Payee address; City;
Reimbursement from
0 political contributions
intended
Category (See categories listed at the top of this schedule)PURPOSE
OF
EXPENDITURE
Payee nameDate
Payee address; City:Amount ($)
Reimbursement from
0 pohlical contributions
Intended
Category (See categorres listed althe top of this schedule)PURPOSE
OF
EXPENDITURE
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Salaries/Wages/Contract Labor Loan Repayment/Reimbursement
Solicitation/Fundraising Expense Transportation Equipment & Related Expense
Travel In District ContributionslDonations Made By
Travel Out Of District Candidate/Officeholder/Political Committee
Office Overhead/Rental Expense OTHER (enter a category not listed above)
3 ACCOUNT # (Ethics Commission Filers)
State; Zip Code
(b) Descriptio n (If travel outside of Texas, complete Schedule T)
State; Zip Code
Description (If travel outside of Texas. complete Schedule T)
State; Zip Code
Description (If travel outside of Texas, complete Schedule T)
-.... .... ..,....
L l1 P
r~~-L'
~ State; Zip Code
"U
:::J: rs;
--
Description (If travet outside of Texas. complete Schedule T)
!
~.
www.ethics.state.tx.us Revised 04/19/2013
_. TexaS' Ethics Commission PO. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
TO A BUSINESS OF etOH
Advertising Expense Gift/Awards/Memorials Expense
Accounting/Banking Legal Services
Consulting Expense Food/Beverage Expense
Event Expense Polling Expense
Fees Printing Expense
1 Total pages Schedule H: 2 FILER NAME
4 Date 5 Business name
6 Amount ($) 7 Business address;
8 PURPOSE
OF
EXPENDITURE
9 Corrplete 00l.Y if direct
expenditure to benefit CIOH
Date Business name
Amount ($) Business address;
PURPOSE
OF
EXPENDITURE
Corrplete ~if direct
expenditure to benefit CIOH
Date Business name
Amount ($) Business address;
PURPOSE
OF
EXPENDITURE
Corrplete ONLY if direct
expenditure to benefit CIOH
Date Business name
Amount ($) Business address;
PURPOSE
OF
EXPENDITURE
Corrplete ONLY if direct Candidate 1 Officeholder name
expenditure to benefit CIOH
PAYMENT FROM POLITICAL CONTRIBUTION ~\
EXPENDITURE CATEGORIES FOR BOX 8(a)
Salaries/Wages/Contract Labor
Solicitation/Fundraising Expense
Travel In District
Travel Out Of District
Office Overhead/Rental Expense
RIGINA CHEDULE H
Loan Repayment/Reimbursement
Transportation Equipment & Related Expense
ContributionslDonations Made By
Cand idate/Officehoider/Pol itical Committee
OTHER (enter a category not listed above)
The Instruction Guide explains how to complete this form.
13 ACCOUNT # (Ethics Commission Filers)
(a) Category (See cetegories listed at the top of this schedule) (b) Description (If travel outside of Texas, complele Schedule T)
Candidate 1 Officeholder name Office sought Office held
Category (See categories listed at the lop of this schedule) Description (If travel outside of Texas, complete Schedule T)
Candidate 1 Officeholder name Office sought Office held
Category (See categories listed althe top of Ihis schedule) Description (If travel outside of Texas, complete Schedule T)
Candidate 1 Officeholder name Office sought Office held
-...
..&' "'ft
:.J ~
:2: ~: ...--.
W i
~
:x "U tTlN
Category (See categories listed althe top of this schedule) Description (If travel outside ofTexas, complete Scl>aQlJle T) I -
.&:-..f
Office sought Office held
City; State; Zip Code
City; State; Zip Code
City; State; Zip Code
City; State; Zip Code
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
www.ethics.state.tx.us Revised 04/19/2013
_ Texas Ethics Commission PO Box 12070 Austin Texas 78711-2070 (512)463-5800 (TOO 1-800-735-2989)
1 Total pages Schedule I:
4 Date
6 Amount ($)
8 PURPOSE
OF
EXPENDITURE
Date
Amount ($)
PURPOSE
OF
EXPENDITURE
Date
Amount ($)
PURPOSE
OF
EXPENDITURE
Date
Amount ($)
PURPOSE
OF
EXPENDITURE
The Instruction Guide explains how to complete this form.
2 FILER NAME
5 Payee name
7 Payee address; City; State; Zip Code
(a) Category (See instructions for examples of acceptable
categories) required.)
Payee name
Payee address; City; State; Zip Code
(a) Category (See instructions for examples of acceptable
categories) required.)
Payee name
Payee address; City; State; Zip Code
(a) Category (See instructions for examples of acceptable
categories) required.)
Payee name
Payee address; City; State; Zip Code
(a) Category (See instructions for examples of acceptable
categories) required.)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
NON-POLITICAL EXPENDITURES SCHEDULE I
MADE FROM POLITICAL CONTRIBUTIONS [)ORIGINAL
3 ACCOUNT # (Ethics Commission Filers)
(b) Description (See instrucllons regarding type of information
(b) Description (See instructions regarding type of information
(b) Description (See instructions regarding type of information
-...
"'Ii'-l:'--
:D; j r '"
-""'---r:a
~ ,
<:J ::r
is> J
,.-1... "~
(b) Description (See instructions regarding type of information
www.ethics.state.tx.us Revised 04/19/2013
Texa~ Ethics Commission PO. Box 12070 Austin, Texas 78711-2070
2 FILER NAME
4 Date
Date
Date
Date
The Instruction Guide explains how to complete this form.
5 Name of person from whom amount is received
6 Address of person from whom amount is received; City; State; Zip Code
7 Purpose for which amount is received
Name of person from whom amount is received
Address of person from whom amount is received; City; State; Zip Code
Purpose for which amount is received
Name of person from whom amount is received
Address of person from whom amount is received; City; State; Zip Code
Purpose for which amount is received
Name of person from whom amount is received
Address of person from whom amount is received; City; State; Zip Code
Purpose for which amount is received
(512) 463-5800 (TOO 1-800-735-2989)
INTEREST EARNED, OTHER CREDITS/GAINS/
SCHEDULE KREFUNDS, AND PURCHASE OF INVESTMENTS
OORIGINAl
1 Total pages Schedule K:
3 ACCOUNT # (Ethics Commission Filers)
8 Amount
($)
Amount
($)
Amount
($)
--l. .-.~~
A~nt !
..w
W {
'"0::.:
N.. -z:
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
www.ethics.slate.tx.us Revised 04/19/2013
Texa~ Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
2 FILER NAME
4
5 Contribution / Expenditure reporte
D Schedule A
D Schedule H
6 Dates of travel 7
8
9
10 Means of transportation
d on:
Contribution / Expenditure reported
D Schedule A
D Schedule H
Dates of travel
Means of transportation
Contribution / Expenditure reported
D Schedule A
D Schedule H
Dates of travel
Means of transportation
on:
on:
IN-KIND CONTRIBUTION OR POLITICAL EXPENDITURE
FOR TRAVEL OUTSIDE OF TEXAS oORIGINAL
1 Total pages Schedule T:The Instruction Guide explains how to cOlTlllete this fonn
3 ACCOUNT#
Name of Contributor / Corporation or Labor Organization / Pledgor / Payee
Sctledule B Schedule C Schedule 0 Schedule FD D D D D
D Schedule N D COH-UC D COH-T D PAC-C D
Name of person(s) traveling
Departure city or name of departure location
Destination city or name of destination location
11 Purpose of travel (including name of conference, seminar, or other event)
Name of Contributor / Corporation or Labor Organization / Pledgor / Payee
Sctledule B Schedule C Schedule 0 Schedule FD D D D D
D Schedule N D COH-UC D COH-T D PAC-C D
Name of person(s) traveling
Departure city or name of departure location
Destination city or name of destination location
Purpose of travel (including name of conference, seminar, or other event)
Name of Contributor / Corporation or Labor Organization / Pledgor / Payee
Schedule B Schedule C Schedule 0 Schedule FD D D D D
Schedule N COH-UC COH-T PAC-CD D D D D
Name of person(s) traveling
Departure city or name of departure location
Destination city or name of destination location
Purpose of travel (including name of conference, seminar, or other event)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
SCHEDULE T
Schedule G
PAC-E
Schedule G
PAC-E
Schedule G
PAC-E
-~ '}C-.
.:-• -t~c.,
!.J
"0 rn'
0-.e
(Ethics Commission Filers)
~
"'," -
www.elhics.slale.lx.us Revised 04/19/2013
1
4
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
CANDIDATE I OFFICEHOLDER REPORT:
FORM C/OH -FRDESIGNATION OF FINAL REPORT
rt """'"'11'.1 A 1
a::=:::>-.••- • •.. ,.,..The Instruction Guide explains how to complete this form .
•• Complete only if "Report Type" on page 1 is marked "Final Report" ••
2 ACCOUNT # (Ethics Commission Filers) C/OH NAME
3 SIGNATURE
I do not expect any further political contributions or political expenditures in connection with my candidacy. I understand that designating a
report as a fi~al report terminates my campaign treasurer appointment. I also understand that I may not accept any campaign contributions
or make any campaign expenditures without a campaign treasurer appointment on file.
Signature of Candidate 1 Officeholder
FILER WHO IS NOT AN OFFICEHOLDER
•• Complete A & B below only if you are notan officeholder.••
A. CAMPAIGN FUNDS
Check only one:
D I do not have unexpended contributions or unexpended interest or income earned from political contributions. W 1
D I have unexpended contributions or unexpended interest or income earned from political contributions. I understandit I nm;
not convert unexpended political contributions or unexpended interest or income earned on political contributions t~rso alb
use. I also understand that I must file an annual report of unexpended contributions and that I may not retain une:fPende9.
contributions or unexpended interest or income earned on political contributions longer than six years after filing this final
report. Further, I understand that I must dispose of unexpended political contributions and unexpended interest or income
earned on political contributions in accordance with the requirements of Election Code, § 254.204.
B. ASSETS
Check only one:
D I do not retain assets purchased with political contributions or interest or other income from political contributions.
D I do retain assets purchased with political contributions or interest or other income from political contributions. I understand that
I may not convert assets purchased with political contributions or interest or other income from political contributions to personal
use. I also understand that I must dispose of assets purchased with political contributions in accordance with the requirements
of Election Code, § 254.204.
Signature of Candidate
5 OFFICEHOLDER
•• Complete this section only if you are an officeholder ••
D I am aware that I remain subject to filing requirements applicable to an officeholder who does not have a campaign treasurer on file.
I am also aware that I will be required to file reports of unexpended contributions if, after filing the last required report as an
officeholder, I retain political contributions, interest or other income from political contributions, or assets purchased with political
contributions or interest or other income from political contributions.
Signature of Officeholder
www.ethics.state.tx.us Revised 04/19/2013