Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) CORRECTED FORM LA AND GOOD-FAITH AFFIDAVIT 1 ACCOUNT # TITLE; FIRST; MI 2 Total pages filed: 3 REGISTRANT OFFICE USE ONLY NICKNAME; LAST; SUFFIX 4 ORIGINAL REPORT TYPE Regular (Monthly) Due Date: Modified (Annual) Exceeded $1000 5 ORIGINAL PERIOD COVERED Month 6 EXPLANATION OF CORRECTION 7 AFFIDAVIT AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said _________________________________ , this the __________ day of __________________ , 20 __________ , to certify which, witness my hand and seal of office. Signature of officer administering oath Remember To Attach Any Part Of Form LA Needed To Report And Explain Corrections www.ethics.state.tx.us Revised 11/01/2007 American LegalNet, Inc. www.FormsWorkFlow.com Final Report HD / PM Receipt # Year Month Day Year Legal Date Processed Date Imaged Amount Totals Day THROUGH I swear, or affirm, under penalty of perjury, that this corrected report is true and correct. I further affirm that I have complied with Section 305.028, Government Code (Prohibited Conflicts of Interest). 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 original 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 Registrant Printed name of officer administering oath Title of officer administering oath Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) CORRECTED FORM LA LOBBY ACTIVITIES REPORT Under section 571.0771 of the Government Code, a filer is subject to a $500 late-filing penalty in connection with a report that is corrected after the filing deadline 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. A filer who files a corrected report after the filing deadline must submit a correction affidavit. The correction affidavit must identify the information that has changed. INSTRUCTIONS FOR COMPLETING THIS FORM The following numbers correspond to the numbered boxes on the other side. 1. Account #. When you registered with the Ethics Commission, you should have received a letter acknowledging receipt of your lobby registration and assigning you an account number. Put that number in this box. 2. Total Pages Filed. After completing this form and any attachments, count the number of pages. Enter that number in this box. Each side of a two-sided form counts as a page. In other words, this form is two pages. 3. Registrant Name. Put your full name here. Enter your name in the same way as on the report you are correcting. 4. Original Report Type. Mark the type of report you are correcting. 5. Original Period Covered. Enter the period covered by the report you are correcting. The year is important because filers sometimes correct reports years after filing the original. 6. Explanation of Correction and Penalty Waiver/Reduction Request. Attach any parts of Form LA (Lobby Activities Report) needed to report and explain corrections. Explain why there was an error on the original report. Also explain what information is being corrected and how the new information is different from the information on the original report. (Use additional pages if you need more space.) You may also use this area to request a waiver or reduction of a late-filing penalty and state the basis of your request. 7. Affidavit. Read the affidavit before signing. You must sign the affidavit in the presence of an individual authorized to take oaths. If signed before a notary public, the affidavit must include the notary's signature and seal. www.ethics.state.tx.us Revised 11/01/2007 American LegalNet, Inc. www.FormsWorkFlow.com