Confidential Social Security Information
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Confidential Social Security Information Form. This is a Texas form and can be use in Ethics Commission Statewide.
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Tags: Confidential Social Security Information, Texas Statewide, Ethics Commission
Texas Ethics Commission
P.O. Box 12070
Austin, Texas 78711-2070
(512) 463-5800
(TDD 1-800-735-2989)
CONFIDENTIAL
SOCIAL SECURITY INFORMATION
FORM
SSN
A lobby registrant must submit this form to the Texas Ethics Commission in compliance with Tex. Fam. Code Sec.
231.302(c)(1), not as a means to register as a lobbyist. To register with the Texas Ethics Commission as a lobbyist,
you must file the LOBBY REGISTRATION (FORM REG) with a filing fee.
1
REGISTRANT NAME
2
REGISTRANT'S
HOME ADDRESS
LICENSE / ACCOUNT #
(Address / PO Box, Apt/ Suite #)
PAGE #
OFFICE USE ONLY
(City, State, Zip Code)
3
SOCIAL SECURITY
NUMBER
NOTE: The Social Security Number WILL NOT be disclosed in any public file or on any
public document maintained by the Texas Ethics Commission.
___________ - _________ - __________
4
DATE OF BIRTH
Month
Day
/
5
Year
/
HD / PM
EMPLOYER NAME
Receipt #
6
EMPLOYER'S
ADDRESS
Amount
Legal
(Address / PO Box, Apt/ Suite #)
Date Processed
(City, State, Zip Code)
Date Imaged
7
SIGNATURE
To the best of my knowledge the accompanying document is true
and correct and includes all information to be reported by me under
Chapter 231, Subchapter D, Family Code.
_____________________________________________________________
Signature of Registrant
www.ethics.state.tx.us
Revised 11/30/2004
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