HomeMy WebLinkAboutKeith Self 01152104Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 1-800-325-8506
l'\.:Revi.e~06/27/2 . 8
CANDIDATE I OFFICEHOLDER FORM C/OH
CAMPAIGN FINANCE REPORT [)ORIGINAl COVER SHEET PG 1
1 ACCOUNT # 2 Total pages filed: 4The C/OH Instruction Guide explains how to complete this form. (Ethics Commission filers)
3 CANDIDATE I MS/MRS/eJ {;/'W ......... MI ",\~.;.~ ~LYOFFICEHOLDER ...... ~ ..' ....
NAME ~r\~\.. -. . . . . . . . .
NICKNAME LAST SUFRX !(~lSclf E : ! =
4 CANDIDATE I ADDRESS / PO BOX: APT /SUlTEIt; CITY; STATE; ZIP CODE ~~\ .J ~f
OFFICEHOLDER '?>-J'I 8Iu/'f'/AJooJ /Tile:" /YlCK/AJtlo/-7X ?!h7o ~ \5'...... , ,;,.~. ;,~,. .....~. ...... ,,'
MAILING "''':.•' ............... .~
ADDRESS DmeH ostmar1<ed
D Change of Address
L..-'"'''"llllt'''\\Tl'
5 CANDIDATE! AREA CODE PHONE NUMBER EXTENSION rooJ,-L"_
OFFICEHOLDER (Pltj) '151-50/5'
Receipt" IAmount
PHONE
Date Processed
6 CAMPAIGN loiS/MRS€) FIRST loll ,~ I~ -If
TREASURER C/I){'~~C Date Imaged
1-1..;--/4NAME . . . . .. . .... . .
NICKNAME LAST SUFRX
hJdQV Tr:
7 CAMPAIGN 5-3~S.z;~h';;j~j'C:·~eJ";;;9(;:;;;"J-~CODE
TREASURER Ii 1~7o
ADDRESS
(Residence or business)
8 CAMPAIGN AREA CODE PHONE NUMBER EXTENSION
TREASURER ('/69 ) ~;z~'-/<3~7PHONE
9 REPORT TYPE ~JanuaJY15 D D D 15th day after campaign treasurer 30th day before election Runoff
appointment (office!lolder only)
D July 15 D 8th day before election D Exceeded $500 limit D Final report (Mach CIOH • FR)
10 PERIOD Montll Day Year Month Day Year
COVERED ()7/tJ//~/3 THROUGH 1;;"'/3/. /~/3
11 ELECTION ELECTION DATE ELECTION TYPE
Month Day Year ~ Primary3 / L( /<l..ul'i D Runoll D General D Special
12 OFFICE OFFICE HELD (~any) -ȣ:1 13 OFFICE SOUGHT (~known)
Co CVYJ Tv£" 'le
14 NOnCE I /
OF DIRECT "" Direct campaign expenditures are campaign expenditures made by others without the candidate's prior consent or approval.
CAMPAIGN Candidates are reqUired to disclose this information only if they receive notification of the direct campaign expenditure. ""
EXPENDITURE
BY OTHER Name
INDIVIDUALS
Address / PO Box: Apt / Suite It; City; Stale: Zip Code ....... '''> :l
C
D addilional pages :;z:: "--' -,'{~ rn
boo TnGO TO PAGE 2 :r
\..0 ----,
-J '
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TOO 1-800-735-2989)
CANDIDATE t OFFICEHOLDER REPORT: FORM CtOH
SUPPORT & TOTALS [; . , ...,,'NAl COVER SHEET PG 2
15 ACCOUNT # (Ethics Commission Filers)14 C/OH NAME
16 NOTICE FROM 11-IIS aox IS FOR N01JCE OF POU1ICAl. CONTIlEItJllONS AlX5'lS) OR POU1ICAl. EXPENDllURES IAAIlE BY POUIlCAL CO!lMllTEES TO SUPPORT 1HE
POLITICAL CANDIDATE JOFRCEHOLDER. THESE EXPENDfTURES "AYHAVE BEEN"ADE wrTHOCfT THE CANOIDATE'S OR OFRCEHOWER'S KNOWUDGE OR
COMMITTEE(S) CX)NSENT. CANOIOATES AM) OFFlCEHOUlERS ARE REQUIRB) TO REPORT lIflS lNfOR!lAllON ONlY IF TIlEY RECSIII: N01JCE OF SUCH EXl'ENDIllJRES.
COMMITTEE NAME
COMMITTEE TYPE
o GENERAL
COMM;g~#RE8/Jt,FFwcvt12 /We . o SPECIFIC
Wc.'.f;;VIIJC J 7)< ;5070
o additional pages
17 CONTRIBUTION 1. TOTAL POLITICAL CONTRIBUTIONS OF $50 OR LESS (OTHER THAN
TOTALS 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 $
CONTRIBUTION
BAlANCE
OUTSTANDING
LOAN TOTALS
4.
5.
6.
18 AFFIDAVIT
TOTAL POLITICAL EXPENDITURES $
TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY
OF REPORTING PERIOD $
TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE $LAST DAY OF THE REPORTING PERIOD
DEBORAH JOY PINA
Notary Public
STATE OF TEXAS
M)-ee-. &po A"'I\lSI'1, lOl6
AFFIX NOTARY STAMP I SEAL ABOVE
subscribed before me, by the said J_~-t_e-'·_~ 5=-_e_/_F .this the
day of ,20 ttl to certify Which, witness my hand and seal of office.
www.ethics.slale.lx.us Revised 09/28/2011
Texas Ethics Commission PO. Box 12070 Austin Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989)
POLITICAL CONTRIBUTIONS
rCHEDULEAOTHER THAN PLEDGES OR LOANS
1 Total pages Schedule A: The Instruction Guide explains how to complete this form.
3 ACCOUNT # (Ethics Commission Filers) 2 FILER NAME ~~l·(
4 Date 5 Full name of contributor 0 out-of-state PAC (LOI/:. ------ll 7 Amount of I 8 In-kind contribution
f) ~' contribution ($) I description (if applicable)/Y11 k e-tJ-1-ta'J; lA It t'. K:; 1~-ey
6 Contributor address; City; State; Zip Code i s,5)" I t&lJt:f. .~
<6;J--2 Ccdo.-v-Cy~~ LYI :fe.c8fh'&t.
A-IJ e,.1 'j;'{, 7·~tJO.2(If travel outside of Texas, complete Schedule T)
9 Principal o=upation I Job title (See Instructions) 110 Employer (See Instructions)
Date FU&~:njrcoii1:~rJl SO out-of·state PAC (LOll:
conq6)OddrM~. '{C~~!StatU Code
l-o..IfV/eu'J 'r;< 7b--af9
Amount of I In-kind contribution
contribution ($) I description (if applicable)
I
I
I
(If travel outside of Texas complete Schedule n
Principal occupation I Job litle (See Instructions) Employer (See Instructions)I
Full name of contributor o out-of-slal"PAC{IOl': -----') Amount of I In-kind contribution
contribution ($) I description (if applicable)
Date
Contributor address; City; State; Zip Gode I
I
I
(If travel outside of Texas, complete Schedule T)
Principal o=upation I Job title (See Instructions) Employer (See Instructions)
I
Amount of I In-kind contribution
contribution ($) I description (if applicable)
Full name of contributor o out-of-staLe PAC (LOII: ----.JlDate
Contributor address; City; State; Zip Code I
I
I
(If travel outside of Texas, complete Schedule n
Principal occupation I Job title (See Instructions) Employer (See Instructions)
I
Amount of I In-kind contribution
contribution ($) I description (if applicable)
Date Full name of contributor o out·of-state PAC (LD#: ------ll
Contributor address; City; State; Zip Code I
I 1
I -
(If travel outside of Texas, complet~hedule n
Principal o=upation I Job title (See Instructions) Employer (See Instructions)
I
ATTACH ADDIT ONAl COPIES OF THIS SCHEDULE AS NEEDED ~
If contributor is out-of-state PAC, please see instruction guide foradditional reporting requirements.
www.ethics.slale.lx.us Revised 04/19/2013
PURPOSE
OF
EXPENDITURE
Complete Q.t:i!.Y. if direct
<
:z
U1
(TOO 1-800-735-2989) Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800
SCHEDULE FPOLITICAL EXPENDITURES
EXPENDITURE CATEGORIES FOR BOX 8(a)
GiftlAwardsfMemorials Expense SalarieslWagesJContract Labor Loan RepaymenURelmbursement Advertising Expense
Legal Services Solicitation/Fundraising Expense Transportation Equipment & Related Expense AccountlngfBanking
Food/Beverage Expense Travel In District Contributions/Donations Made By
Polling Expense Travel Out Of District Candidate/Officeholder/Political Committee
Consulting Expense
Event Expense
Fees
Printing Expense Offlce Overhead/Rental Expense OTHER (enter a category not listed above)
The Instruction Guide explains how to complete this fonn.
3 ACCOUNT # (Ethics CofTllT"ission Filers)1 Total pages Schedule F: 2
7 Payee address: City; State; Zip Code6 Amount ( ) /ql/ oLor{/}-//lI~
/fllc'/\J l
, 7X 75{,)oZ.
~ Description (If travel outslde of Texas. complete Schedule T)(a) Category (See categories listed at the lop of this schedule)8 PURPOSE
OF
EXPENDITURE
Office sought Office held9 Complete QM.Y if direct
expenditure to benefit CfOH
Description (If IravaI outllide of Texas, complete !ichedulo T)
Office sought Office held
expenditure to benefit C/OH
Complete .QIiLY. if direct Office sought Office held
Description (If tnIvel outside of TeXB&. complote Schedute T)
expenditure to benefit ClOH
DeSCfiption (If travel outside of Texas. completa S
OffIce sought Office held
Arno t ($)
5!Jr?
PURPOSE
OF
EXPENDITURE
Complete .Qt!LY if direct
expenditure 10 benefit C/OH
ATIACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
www.elhics.SlaIQ.lxus Revised 09/28/2011