CANDIDATE / OFFICEHOLDER REPORT OF UNEXPENDED CONTRIBUTIONS The C/OH-UC Instruction Guide explains how to complete this form. 2 CANDIDATE / OFFICEHOLDER NAME C/OH-UC COVER SHEET PG 1 FORM 1 Filer ID (Ethics Commission Filers) MS/MRS/MR FIRST MI OFFICE USE ONLY Date Received NICKNAME LAST SUFFIX 3 CANDIDATE / OFFICEHOLDER ADDRESS change of address ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE Date Hand-delivered or Date Postmarked 4 5 REPORT TYPE PERIOD COVERED TOTALS 1. Month Annual Day Year Final Disposition Month Day Year Date Imaged THROUGH 6 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 ______________________________________, ___________ 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 Receipt # Amount $ Date Processed $ $ this the Revised 11/3/2015 American LegalNet, Inc. www.FormsWorkFlow.com C/OH REPORT OF UNEXPENDED CONTRIBUTIONS EXPENDITURES 8 C/OH NAME FORM C/OH-UC PG 2 9 Filer ID (Ethics Commission Filers) 10 Date 11 Payee name 13 Amount ($) 12 Payee address; City; State; Zip Code 14 Purpose of expenditure (See instructions regarding type of information required.) 15 Is expenditure a contribution to a candidate, officeholder, or political committee? Check if travel outside of Texas. Complete Schedule T. Date Payee name Amount ($) Payee address; City; State; Zip Code Purpose of expenditure (See instructions regarding type of information required.) Is expenditure a contribution to a candidate, officeholder, or political committee? Check if travel outside of Texas. Complete Schedule T. Date Payee name Amount ($) Payee address; City; State; Zip Code Purpose of expenditure (See instructions regarding type of information required.) Is expenditure a contribution to a candidate, officeholder, or political committee? Check if travel outside of Texas. Complete Schedule T. Date Payee name Amount ($) Payee address; City; State; Zip Code Purpose of expenditure (See instructions regarding type of information required.) Is expenditure a contribution to a candidate, officeholder, or political committee? 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 Yes No Yes No Yes No Yes No Revised 11/3/2015 American LegalNet, Inc. www.FormsWorkFlow.com