CORRECTION/AMENDMENT AFFIDAVIT FOR POLITICAL COMMITTEE 1 Filer ID (Ethics Commission Filers) 2 Total pages filed: FORM COR-PAC OFFICE USE ONLY Date Received 3 COMMITTEE NAME 4 TREASURER NAME 5 ORIGINAL REPORT TYPE January 15 July 15 30th day before election 8th day before election Runoff 10th day after campaign treasurer termination Dissolution Report Other (specify _________________________ Date Hand-delivered or Date Postmarked Receipt # Amount $ 6 ORIGINAL PERIOD COVERED Month Day Year Month Day Year Date Processed THROUGH Date Imaged 7 EXPLANATION OF CORRECTION 8 AFFIDAVIT I swear, or affirm, under penalty of perjury, that this corrected report is true and correct. Check ONLY if applicable: Semiannual reports: I swear, or affirm, that the original report was made in good faith and without an intent to mislead or to misrepresent the information contained in the report. Other reports: 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. AFFIX NOTARY STAMP / SEAL ABOVE Signature of Campaign Treasurer 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 Printed name of officer administering Title of officer administering oath Remember To Attach Any Part Of The Campaign Finance Report Form Needed To Report And Explain Corrections Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 04/27/2015 American LegalNet, Inc. www.FormsWorkFlow.com CORRECTION/AMENDMENT AFFIDAVIT FOR POLITICAL COMMITTEE All Reports: A filer who files a corrected report must submit a correction affidavit. The affidavit must identify the information that has changed. Reports filed with Texas Ethics Commission: A corrected report (other than a report due 8 days before an election or a special report near election) filed with the Ethics Commission after its due date is not considered late for purposes of late-filing penalties if: (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. Semiannual Reports: Effective September 1, 2011, a semiannual report (due January 15 or July 15) that is amended/corrected before the eighth day after the original report was filed is considered to have been filed on the date the original report was filed. A semiannual report that is amended/corrected on or after the eighth day after the original report was filed is considered to have been filed on the date the original report was filed if: (1) the amendment/correction is made before any complaint is filed with regard to the subject of the amendment/correction; and (2) the original report was made in good faith and without intent to mislead or misrepresent the information contained in the report. Attach additional pages as necessary. INSTRUCTIONS FOR COMPLETING THIS FORM The following numbers correspond to the numbered boxes on the other side. 1. Filer ID. If you file with the Ethics Commission, you should have received a letter acknowledging receipt of your campaign treasurer appointment and assigning you an Filer ID. Put that number in this box. If you do not file with the Ethics Commission, skip 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. Committee Name. Put the committee's full name here. Enter your name in the same way as on the report you are correcting. 4. Treasurer Name. Put the treasurer's full name here. 5. Original Report Type. Mark the type of report you are correcting. 6. 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. 7. Explanation of Correction. Attach any part of the campaign finance report form 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. 8. 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. Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 04/27/2015 American LegalNet, Inc. www.FormsWorkFlow.com