Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) CORRECTED FINANCIAL STATEMENT AND OFFICE USE ONLY GOOD-FAITH AFFIDAVIT Attach Any Part of Your Financial Statement Form Needed to Report and Explain Corrections Filer Name (First, MI, Last) Account # Receipt # Address (P.O. Box or Street Address, Apt. or Suite #) Amount HD / PM Date Processed (CHECK IF FILER'S HOME ADDRESS) (City, State, Zip Code) Date Imaged The correction(s) filed with this affidavit apply to my financial statement due in 2014 2013 2012 2011 2010 2009 Other (Remember: The financial statement you file covers the preceding calendar year's activity. Thus a report due in 2014 covers information for calendar year 2013.) Explanation of Correction I swear, or affirm, under penalty of perjury, that this corrected report is true and correct. Check ONLY if applicable: I swear, or affirm, that I am filing this corrected report not later than the 14th business day after the date I learned that the report as originally filed is inaccurate or incomplete. I swear, or affirm, that any error or omission in the report as originally filed was made in good faith. Signature of Filer AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me by _______________________________________________ this the ___________ day of _________________________, 20 ___________, to certify which, witness my hand and seal of office. Signature of officer administering oath Print name of officer administering oath Title of officer administering oath www.ethics.state.tx.us Revised 10/24/2013 American LegalNet, Inc. www.FormsWorkFlow.com Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) CORRECTED FINANCIAL STATEMENT AND GOOD-FAITH AFFIDAVIT All Reports: A filer who files a corrected financial statement must submit a correction affidavit. The affidavit must identify the information that has changed. Reports filed with Texas Ethics Commission: A corrected financial statement filed with the Ethics Commission after its due date is considered late for purposes of late-filing penalties unless: (1) any error or omission in the report as originally filed was made in good faith, and (2) the person filing the report files a corrected report and a good-faith affidavit not later than the 14th business day after the date the person learns that the report as originally filed is inaccurate or incomplete. Attach additional pages as necessary. www.ethics.state.tx.us Revised 10/24/2013 American LegalNet, Inc. www.FormsWorkFlow.com