Texas Ethics Commission P.O. Box 12070 AMENDMENT: Austin, Texas 78711-2070 (512) 463-5800 APPOINTMENT OF A 1-800-325-8506 FORM CAMPAIGN TREASURER BY A CANDIDATE 1 2 CANDIDATE NAME 3 ACCOUNT # ACTA PG 1 Total pages filed: See ACTA INSTRUCTION GUIDE for detailed instructions. Use this form for changes to existing information only. Do not provide information previously disclosed. MS / MRS / MR NEW 4 FIRST MI OFFICE USE ONLY CANDIDATE NAME Date Received ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ APT / SUITE #; ○ ADDRESS / PO BOX; ○ ○ ○ ○ ○ NEW 5 LAST ○ NICKNAME SUFFIX CITY; STATE; ZIP CODE CANDIDATE MAILING ADDRESS Date Hand-delivered or Date Postmarked NEW 6 CANDIDATE PHONE AREA CODE ( PHONE NUMBER EXTENSION ) Date Processed NEW 7 Date Imaged OFFICE HELD (if any) 8 NEW OFFICE SOUGHT (if known) NEW MS / MRS / MR NEW 9 FIRST MI STREET ADDRESS (NO PO BOX PLEASE); NEW AREA CODE NICKNAME APT / SUITE #; CITY; LAST SUFFIX CAMPAIGN TREASURER NAME 10 STATE; ZIP CODE CAMPAIGN TREASURER STREET ADDRESS (Residence or business) 11 CAMPAIGN TREASURER PHONE 12 CANDIDATE SIGNATURE ( PHONE NUMBER EXTENSION ) 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. Signature of Candidate Date Signed GO TO PAGE 2 Printed on recycled paper American LegalNet, Inc. www.USCourtForms.com (Revised 09/01/2003) Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 AMENDMENT: 1-800-325-8506 FORM CANDIDATE MODIFIED REPORTING DECLARATION ACTA PG 2 13 CANDIDATE NAME 14 NEW MODIFIED REPORTING DECLARATION COMPLETE THIS SECTION ONL IF YOU ARE CHOOSING MODIFIED Y REPORTING. •• This declaration must be filed no later than the 30th day before the first elec­ tion to which the declaration applies. •• •• The modified reporting option is valid for one election cycle only. •• (An election cycle includes a primary election, a general election, and any related runoffs.) I do 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. I understand that if either one of those limits is exceeded, I will be required to file pre-election reports and, if necessary, a runoff report. Date of election(s) or election cycle to which declaration applies Signature of Candidate This appointment is effective on the date it is filed with the appropriate filing authority. Printed on recycled paper American LegalNet, Inc. (Revised 09/01/2003) www.USCourtForms.com