3 C-OH - pages 1-3CANDIDATE / OFFICEHOLDER
FORM C /OH
CAMPAIGN FINANCE REPORT
COVER SHEET PG 1
1
Filer ID (Ethics Commission Filers)
2 Total pages filed:
The C /OH Instruction Guide
explains how to complete this form.
3 CANDIDATE/
MS / MRS / MR FIRST
MI
OFFICE USE ONLY
OFFICEHOLDER
NAME
Date Received
NICKNAME LAST
SUFFIX
4 CANDIDATE/
ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE
OFFICEHOLDER
MAILING
ADDRESS
❑ Change of Address
5 CANDIDATE/
AREA CODE PHONE NUMBER
EXTENSION
Date Hand - delivered or Date Postmarked
OFFICEHOLDER
/ 1
PHONE
` I
6 CAMPAIGN
MS / MRS / MR FIRST
MI
Receipt #
Amount $
TREASURER
Date Processed
NAME
. . . . . . . . . . . . . . . . . . . . . . . . .
NICKNAME LAST
SUFFIX
Date Imaged
7 CAMPAIGN
STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE
#; CITY; STATE;
ZIP CODE
TREASURER
ADDRESS
(Residence or Business)
8 CAMPAIGN
AREA CODE PHONE NUMBER
EXTENSION
TREASURER
PHONE
/
9 REPORT TYPE
El January 15 F-1 30th day before election
El Runoff
� 15th day after campaign
treasurer appointment
(Officeholder Only)
❑ July 15 ❑ 8th day before election
❑ Exceeded $500 limit
❑ Final Report (Attach C /OH - FR)
10 PERIOD
Month Day Year
Month
Day Year
COVERED
THROUGH
11 ELECTION
ELECTION DATE
ELECTION TYPE
❑ Primary
❑ Runoff ❑ Other -
Month Day Year
Description
❑ General
❑ Special
12 OFFICE
OFFICE HELD (if any)
13 OFFICE SOUGHT (if known)
GO TO PAGE 2
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
CANDIDATE OFFICEHOLDER
It FORM C /OH
CAMPAIGN FINANCE REPORT COVER SHEET PG 2
14 C /OH NAME
15 Filer ID (Ethics Commission Filers)
16 NOTICE FROM
THIS BOX IS FOR NOTICE OF POLITICAL CONTRIBUTIONS ACCEPTED OR POLITICAL EXPENDITURES MADE BY POLITICAL COMMITTEES TO
POLITICAL
SUPPORT THE CANDIDATE / OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATES OR OFFICEHOLDERS
COMMITTEE(S)
KNOWLEDGE OR CONSENT. CANDIDATES AND OFFICEHOLDERS ARE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY RECEIVE NOTICE
OF SUCH EXPENDITURES.
COMMITTEE TYPE
COMMITTEE NAME
FI GENERAL
COMMITTEE ADDRESS
SPECIFIC
COMMITTEE CAMPAIGN TREASURER NAME
❑ Additional Pages
COMMITTEE CAMPAIGN TREASURER ADDRESS
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
4. TOTAL POLITICAL EXPENDITURES
CONTRIBUTION
BALANCE
5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY
OF REPORTING PERIOD
OUTSTANDING
6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
LOAN TOTALS
LAST DAY OF THE REPORTING PERIOD
18 AFFIDAVIT
I swear, or affirm, under penalty of perjury, that the accompanying report is
true and correct and includes all information required to be reported by me
under Title 15, Election Code.
Signature of Candidate or Officeholder
AFFIX NOTARY STAMP/ SEALABOVE
Sworn to and subscribed before me, by the said this the
day of
.20— to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
SUBTOTALS
- C /OFD FORM C /OH
COVER SHEET PG 3
19
FILER NAME
20 Filer ID (Ethics Commission Filers)
21
SCHEDULE SUBTOTALS
NAME OF SCHEDULE
SUBTOTAL
AMOUNT
1•
SCHEDULEAi:
MONETARY POLITICAL CONTRIBUTIONS
$
2•
SCHEDULE A2:
NON-MONETARY (IN-KIND) POLITICAL CONTRIBUTIONS
$
3.
SCHEDULE B: PLEDGED CONTRIBUTIONS
$
4.
SCHEDULE E:
LOANS
$
5.
SCHEDULE F1:
POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS
$
6.
El
SCHEDULE F2:
UNPAID INCURRED OBLIGATIONS
$
7•
SCHEDULE F3:
PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS
$
8•
SCHEDULE F4:
EXPENDITURES MADE BY CREDIT CARD
$
9•
El
SCHEDULE G:
POLITICAL EXPENDITURES MADE FROM PERSONAL FUNDS
$
10.
❑
SCHEDULE H:
PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C /OH
$
11.
SCHEDULE I: NON
- POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS
$
12,
❑SCHEDULE
K:
RETURNED TO
INTEREST, CREDITS, GAINS, REFUNDS, AND CONTRIBUTIONS
FILER
$
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015