Scott Larson - Campaign TreasurerTexas Ethics Commission P.O. Box 12070 Austin, Texas 78711 -2070 (512) 463 -5800 (TDD 1- 800 - 735 -2989)
APPOINTMENT OF A CAMPAI N TREA URER FORM CT
BY A CANDIDATE PG 1
See CTA Instruction Guide for detailed instructions.
1 Total pages filed:
2 CANDIDATE
MS /MRS /MR FIRST MI
OFFICE USE ONLY
NAME
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Acct. #
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. . . . . . . . . .
NICKNAME LAST SUFFIX
Dale Received
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3 CANDIDATE
ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE
MAILING`
ADDRESS
`k JA— 1
4 CANDIDATE
AREA CODE PHONE NUMBER EXTENSION
Date Hand - delivered or Postmarked
PHONE
C
0\ % a j 2,o l
J c °l
Date Processed
5 OFFICE
HELD
�l -� A� i
Date Imaged
(if any)
6 OFFICE
SOUGHT
(if known)
7 CAMPAIGN
MSIMRS/MR FIRST MI NICKNAME LAST SUFFIX
TREASURER
NAME
y 0
8 CAMPAIGN
STREETADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; ZIP CODE
TREASURER
STREET
ADDRESS��
(residence or business)
9 CAMPAIGN
AREA CODE PHONE NUMBER EXTENSION
TREASURER
PHONE
\3 ()--) I
10 CANDIDATE
SIGNATURE
I am aware of the Nepotism Law, Chapter 573 of the Texas Government Code.
I am aware of my responsibility to file timely reports as required by title 15 of
the Election Code.
I am aware of the restrictions in title 15 of the Election Code on contributions
from corporations and labor organizations.
7
Signature of Candidate Date Signed
C40 Tn PAC-, F 2