Specific Purpose CommitteeTF,<-_,-_'Fthira (- nmmissinn P.O. Box 12070 Austin. Texas 78711 -2070 (512) 463 -5800 (TDD 1- 800 - 735 -2989)
APPOINTMENT OF A CAMPAIGN TREASURER FORM STA
BY A SPECIFIC-PURPOSE COMMITTEE PG 1
1 Total pages filed:
See STA Instruction Guide for detailed instructions.
t
2
COMMITTEE
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OFFICE USE ONLY
NAME
Acct. #
3
COMMITTEE
ADDRESS /PO BOX; APT /SUITE #; CITY; STATE; ZIPCODE
Date Received
ADDRESS
i.
4 CAMPAIGN
MS / MRS MR FIRST MI(�
TREASURER
NAME
�I OAR ............ .
NICKNAME LAST SUFFIX
n�, v) DA�4
F 'S`TRiEEETADDRESS
HD /PM
5 CAMPAIGN
(NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; ZIP CODE
TREASURER
_ f,—/V\ I 1\l
Date Processed
STREET
ADDRESS
��lj��;'Z ��j��`i
(residence or business)
ii-TA
Date Imaged
6
MAILING
ADDRESS /PO BOX; APT /SUITE #; CITY; STATE; ZIP CODE
ADDRESS
same as above
7
CAMPAIGN
AREA CODE PHONE NUMBER EXTENSION
TREASURER
PHONE
t 6
8
PERSON
FIRST MI LAST SUFFIX
APPOINTING
TREASURER
11
M1 A �i 0 A
9
SIGNATURE
I understand that I have been appointed as the campaign treasurer for this specific - purpose
committee and that I am responsible for filing all required reports and that I may be subject
to fines for failure to do so. I am aware of the restrictions in title 1, of the Election Code on
contributions from corporations and labor organizations.
Signature of Campaign Treasurer
10
ASSISTANT
FIRST MI LAST SUFFIX
CAMPAIGN
TREASURER
(see instructions)
11
ASSISTANT
ADDRESS /PO BOX; APT /SUITE #; CITY; STATE; ZIP CODE
CAMPAIGN
TREASURER
ADDRESS
12 ASSISTANT
AREA CODE PHONE NUMBER EXTENSION
CAMPAIGN
TREASURER
( )
PHONE
CONTINUE ON PAGE 2
www.ethics.state.tx.us Revised 09/04/2014
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711 -2070 (512) 463 -5800 (TDD 1- 800 - 735 -2989)
SPEC IFIC- UJ RPOS E COMMITTEE: FORM STA
PURPOSEAND MODIFIED REPORTING DECLARATION PG
13 COMMITTEE NAME
14 COMMITTEE
CANDIDATE/ OFFICEHOLDER NAME
PURPOSE
SUPPORT CANDIDATE
OPPOSE CANDIDATE
OFFICE SOUGHT (candidate)/ OFFICE HELD (officeholder)
ASSIST OFFICEHOLDER
BALLOT IDENTIFICATION OF MEASURE / # r-,QJJ tN PkOft)ti I'PoN f Z
ELECTION DATE
SUPPORT MEASURE
e)�n<j'F �f�,'O l tfj�prJj I < (
Month / Day / Year
OPPOSE MEASURE
DESCRIPTION
15 MODIFIED
REPORTING
DECLARATION
COMPLETE THIS SECTION ONLY IF YOU ARE CHOOSING
MODIFIED REPORTING.
--This declaration must be filed no later than the 30th day
before the first election to which the declaration applies. •-
--The modified reporting declaration is valid for one election cycle only. ••
(An election cycle includes a primary election, a general election, and any related runoffs.)
The committee does not intend to accept more than $500 in political
contributions or make more than $500 in political expenditures (excluding
filing fees) in connection with any future election within the election cycle.
The committee understands that if either one of those limits is exceeded,
the committee's campaign treasurer will be required to file pre - election
reports and, if necessary, a runoff report.
Year of election(s) or election cycle to Signature of Campaign Treasurer
which declaration applies
ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED
www.ethics.state.tx.us Revised 09/04/2014
I CRt15 CIr IIUJ UU1111111571Ur I Mu. sox -Ituru Husun, texas ttiill -tutu (b12) 463 -bBUU ( IUD 1 -800- 735 -2989)
COME 0"F FAIR CAMPAUGN FORM CFC
PRACTICES OVER SHEET
OFFICE USE ONLY
Pursuant to chapter 258 of the Election Code, every candidate and Date Received
political committee is encouraged to subscribe to the Code of Fair
Campaign Practices. The Code may be filed with the proper filing`
authority upon submission of a campaign treasurer appointment
form. Candidates or political committees that already have a
current campaign treasurer appointment on file as of September 1,
1997, may subscribe to the code at any time. Date Hand - delivered or Postmarked
Date Processed
Subscription to the Code of Fair Campaign Practices is voluntary.
Date Imaged
1 ACCOUNT NUMBER 2 TYPE OF FILER
(Ethics Commission Filers)
CANDIDATE POLITICAL COMMITTEE
If filing as a candidate, complete boxes 3 - 6, If filing for a political committee, complete
then read and sign page 2. boxes 7 and 8, then read and sign page 2.
3 NAME OF CANDIDATE I TITLE(Dr.,Mr.,Ms.,etc.) FIRST
(PLEASE TYPE OR PRINT)
,z➢
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NICKNAME LAST SUFFIX (SR., JR., III, etc.)
4 TELEPHONE NUMBER AREA CODE PHONE NUMBER EXTENSION
OF CANDIDATE 1/
(PLEASE TYPE OR PRINT)
5 ADDRESS OF CANDIDATE STREET/ PO BOX; APT /SUITE #; CITY; STATE; ZIP CODE
(PLEASE TYPE OR PRINT)
6 OFFICE SOUGHT
BY CANDIDATE
(PLEASE TYPE OR PRINT)
7 NAME OF COMMITTEE -54j4r_-M_2_ 80" AN)0 'j�AIZfEy (_Qr,,tj ijTfC-
(PLEASE TYPE OR PRINT)
8 NAME OF CAMPAIGN TITLE (Dr Mr., s., etc.) FIRST MI
TREASURER q
(PLEASE TYPE OR PRINT) h I�/1�
NICKNAME LAST SUFFIX (SR., JR., III, etc.)
GO TO PAGE 2
www.ethics.state.tx.us Revised 11/23/2010
Texas Ethics Commission P.O. Box 12070 Austin, texas /6/11 -2010 (b12) 463 -btfuu (I uu 1 -auu-
There are basic principles of decency, honesty, and fair play that every candidate andpolitical committee inthis state
has amoral obligation to observe anduphold, in orderthat, after vigorously contested but fairly conducted campaigns,
our citizens may exercise their constitutional rights to a free and untrammeled choice and the will of the people may be
fully and clearly expressed on the issues.
THEREFORE:
(1) I will conduct the campaign openly and publicly and limit attacks on my opponent to legitimate challenges to my
opponent's record and stated positions on issues.
(2) I will not use or permit the use of character defamation, whispering campaigns, libel, slander, or scurrilous attacks
on any candidate or the candidate's personal or family life.
(3) I will not use or permit any appeal to negative prejudice based on race, sex, religion, or national origin.
(4) I will not use campaign material of any sort that misrepresents, distorts, or otherwise falsifies the facts, nor will I
use malicious or unfounded accusations that aim at creating or exploiting doubts, without justification, as to the
personal integrity or patriotism of my opponent.
(5) I will not undertake or condone any dishonest or unethical practice that tends to corrupt or undermine our system
of free elections or that hampers or prevents the full and free expression of the will of the voters, including any
activity aimed at intimidating voters or discouraging them from voting.
(6) I will defend and uphold the right of every qualified voter to frill and equal participation in the electoral process,
and will not engage in any activity aimed at intimidating voters or discouraging them from voting.
(7) I will immediately and publicly repudiate methods and tactics that may come from others that I have pledged not
to use or condone. I shall take firm action against any subordinate who violates any provision of this code or the
laws governing elections.
I, the undersigned, candidate for election to public office in the State of Texas or campaign treasurer of a political
committee, hereby voluntarily endorse, subscribe to, and solemnly pledge myself to conduct the campaign in accordance
with the above principles and practices.
Signature
f /C) '15
Date
www.ethics.state,tx.us Revised 11/23/2010