Texas Ethics Commission P.O. Box 12070 AMENDMENT: Austin, Texas 78711-2070 (512) 463-5800 APPOINTMENT OF A CAMPAIGN FORM TREASURER BY A GENERAL-PURPOSE COMMITTEE 1 2 COMMITTEE NAME 4 COMMITTEE NAME ACRONYM COMMITTEE ADDRESS NEW OFFICE USE ONLY NEW 6 ACCOUNT# AGTA PG 1 NEW 5 TOTAL PAGES FILED: 3 See AGTA I NSTRUCTION GUIDE for detailed instructions. 1-800-325-8506 ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; Date Received ZIP CODE Date Hand-delivered or Date Postmarked Receipt # Amount Date Processed REPORTING TYPE NEW 8 CAMPAIGN TREASURER NAME NEW MS / MRS / MR 9 CAMPAIGN TREASURER STREET ADDRESS NEW 7 REGULAR MONTHLY FIRST Date Image MI NICKNAME LAST STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; NEW ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE NEW AREA CODE PHONE NUMBER SUFFIX ZIP CODE (Residence or business) 10 CAMPAIGN TREASURER MAILING ADDRESS same as above 11 CAMPAIGN TREASURER PHONE 12 ( 13 SIGNATURE ) FIRST PERSON APPOINTING TREASURER EXTENSION MI LAST SUFFIX I understand that I have been appointed as the campaign treasurer for this general-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 15 of the Election Code on contributions from corporations and labor organizations. Signature of campaign treasurer 14 ASSISTANT CAMPAIGN TREASURER NEW FIRST 15 NEW ADDRESS / PO BOX; APT / SUITE #; NEW AREA CODE PHONE NUMBER MI CITY; LAST STATE; SUFFIX ZIP CODE ASSISTANT CAMPAIGN TREASURER ADDRESS 16 ASSISTANT CAMPAIGN TREASURER PHONE ( EXTENSION ) CONTINUE ON PAGE 2 This appointment is effective on the date it is filed with the commission. Printed on recycled paper Revised 09/01/2003 American LegalNet, Inc. www.USCourtForms.com Texas Ethics Commission AMENDMENT: P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 GENERAL-PURPOSE COMMITTEE 1-800-325-8506 AGTA PG 2 FORM CONTROLLING ENTITY INFORMATION COMMITTEE NAME ACCOUNT # 18 FULL NAME OF CONTROLLING ENTITY ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ CONTROLLING ENTITY INFORMATION ! add ! delete ○ 19 ○ 17 ACRONYM FULL NAME OF CONTROLLING ENTITY ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ! add ! delete ACRONYM FULL NAME OF CONTROLLING ENTITY ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ! add ! delete ACRONYM FULL NAME OF CONTROLLING ENTITY ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ! add ! delete ACRONYM First Last Suffix MI Last Suffix First MI Last Suffix First MI Last Suffix First MI Last Suffix First MI Last Suffix First MI Last Suffix First MI Last Suffix First MI Last Suffix First CONTRIBUTION DECISION MAKERS MI First 20 MI Last Suffix ! add ! delete ! add ! delete ! add ! delete ! add ! delete ! add ! delete 21 EXPENDITURE DECISION MAKERS ! add ! delete ! add ! delete ! add ! delete ! add ! delete ! add ! delete ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Printed on recycled paper Revised 09/01/2003 American LegalNet, Inc. www.USCourtForms.com Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 GENERAL-PURPOSE COMMITTEE: 1-800-325-8506 AGTA PG 3 FORM RECIPIENT COMMITTEES 23 22 COMMITTEE NAME ADD ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Zip Code Committee name ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ Zip Code ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Committee name ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ Zip Code ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Committee name ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ Zip Code ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Committee name ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ Zip Code ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Committee name ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ Zip Code ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Committee name ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Committee address; ○ ○ ADD City; ○ ○ Committee address; ○ ○ ADD City; ○ ○ Committee address; ○ ○ ADD City; ○ ○ Committee address; ○ ○ ADD City; ○ ○ Committee address; ○ ○ ADD City; ○ ○ Committee address; ○ ○ ADD City; ○ Committee address; ○ RECIPIENT GENERAL PURPOSE COMMITTEES Committee name ○ 24 ACCOUNT # Zip Code ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Printed on recycled paper Revised 09/01/2003 American LegalNet, Inc. www.USCourtForms.com