HomeMy WebLinkAboutKeith Self 07132016 •
• L ORIGINAL
CORRECTION/AMENDMENT AFFIDAVIT
FOR CANDIDATE/OFFICEHOLDER FORM COR-C/OH j
1 Filer ID(Ethics Commission Filers) 2 Total pages filed:
OFFICE USE ONLY
3 CANDIDATE/ MS/MRS/tulR FIRS,T 'l�`�• l MI Date le..
t7lrf, 1'K�/ •,
OFFICEHOLDER A
•
NAME 1 1 t rs
NICKNAME LAST SUFFIX _ 3
4 ORIGINAL REPORT ixJanuary 15 I I Runoff Other(specify) a4
TYPE ' ;;_4;,
July 15 [ I Exceeded$500 limit �'lrhlrn,1110.a��
30th day before electron 15th day after treasurer DateTrid-delivere or Date Postmarked
appointment(officeholder only) ` /
I18th day before election Final report Receipt# Amount$ `'"
5 ORIGINAL PERIOD Month Day Year Month 7 Day Year Date Processed / /
COVERED 7/ 1 /ZO1i /4/3 1 /26/6- ��/ �to
THROUGH Date Imaged
7 ,-7J131> lv
6 EXPLANATIONI. IVOR O O1 1 C-e- hea I k b 18 G/� 1 2 5f C v v s ir.`'.vlt!
!,Z,, )3,1 s cine a., ,674.11e._ pal to Awry la.rsk p
Coryeeif- l-Ap_ peNal be`ditilLoYeriterdof$019•60642i.rr IA
7 AFFIDAVIT I swear,or affirm, under penalty of perjury,that this corrected ._.,.
report is true and correct. 0'
Check ONLY if applicable: -.
XSemiannual reports: I swear,or affirm,that the original reportzwas
made in good faith and without an intent to mislead or to mis pre- „
sent the information contained in the report.
Other reports: I swear, or affirm, that I am filing this corrected
.s..116.1-% DEBORAH JOY PINA report not later than the 14th business day after the date I learned
�� Nmdry public that the report as originally filed is inaccurate or incomplete. I swear,
�,�r SFATEOlF7EXAS or affirm, that any error or omis ion in the re..rt as originally filed
VIPsem MyCems Asps 111.2016 was made in good fai .
c� J
AFFIX NOTARY STAMP / SEAL ABOVE Signature of Candidate• Officeholder
Sworn to and subscribed before me,by the said °I 1 ' ( this the ��7" day of
_
lire,,,_ ,to certify which,wi •-ss my h. d an.s -I of office.
J As,. A /1 __ _ ' �D . A 1/— Ei
-l► i
- • e of officer admi '_ er g oa• Printed name of officer administering oath Title of o.cer -.ministering oath
R- emb- To Attach Any Part Of The Campaign Finance Report Form
Needed To Report And Explain Corrections
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 04/27/2015