4 C-OH-UC Report of Unexpended ContributionsCANDIDATE
/ OFFICEHOLDER FORM C /OH -UC
REPORT OF
UNEXPENDED CONTRIBUTIONS COVER SHEET PG 1
1 FilerlD (Ethics Commission Filers)
The C /OH -UC Instruction Guide explains how to complete this form.
2 CANDIDATE /
MS /MRS /MR FIRST MI
OFFICE USE ONLY
OFFICEHOLDER
Date Received
NAME
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NICKNAME LAST SUFFIX
3 CANDIDATE/
ADDRESS /PO BOX; APT/ SUITE #; CITY; STATE; ZIP CODE
OFFICEHOLDER
Date Hand - delivered or Date Postmark @d
ADDRESS
❑ change of address
Receipt #
Amount $
4 REPORT
❑ Annual ❑ Final Disposition
Date Processed
TYPE
5 PERIOD
Month Day Year Month/ Day Year
Date Imaged
COVERED
/ / THROUGH /
6 TOTALS
1. TOTAL AMOUNT OF UNEXPENDED POLITICAL CONTRIBUTIONS AS OF
DECEMBER 31 OF THE PREVIOUS YEAR.
2. TOTAL AMOUNT OF INTEREST AND OTHER INCOME EARNED ON
UNEXPENDED POLITICAL CONTRIBUTIONS DURING THE PREVIOUS YEAR.
7 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
/ SEAL ABOVE
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 11/3/2015
C /OH REPORT OF UNEXPENDED CONTRIBUTIONS FORM C /OH -UC
EXPENDITURES PG 2
8 C /OH NAME
9 Filer ID (Ethics Commission Filers)
10 Date
11 Payee name
13 Amount
........... ...............................
12 Payee address; City; State; Zip Code
14 Purpose of expenditure (See instructions regarding type of information required.)
15
Is expenditure a contribution � Yes
to a candidate, officeholder, or
No
political committee?
0 Check if travel outside of Texas. Complete Schedule T.
Date
Payee name
Amount
M
. . . . . . . , . . . . . . . . . . . . . . . .
Payee address; City; State; Zip Code
Purpose of expenditure (See instructions regarding type of information required.)
Is expenditure a contribution � Yes
to a candidate, officeholder, or
0 No
political committee?
Check if travel outside of Texas. Complete Schedule T.
Date
Payee name
Amount
M
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Payee address; City; State; Zip Code
Purpose of expenditure (See instructions regarding type of information required.)
Is expenditure a contribution = Yes
to a candidate, officeholder, or
political committee? E:] No
0 Check if travel outside of Texas. Complete Schedule T.
Date
Payee name
Amount
M
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Payee address; City; State; Zip Code
Purpose of expenditure (See instructions regarding type of information required.)
Is expenditure a contribution = Yes
to a candidate, officeholder, or
No
political committee? Q
Check if travel outside of Texas. Complete Schedule T.
ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/3/2015