Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 FORMER CANDIDATE FOR SPEAKER OF THE TEXAS SPK-UC COVER SHEET FORM HOUSE OF REPRESENTATIVES: ANNUAL REPORT OF UNEXPENDED CONTRIBUTIONS TITLE 3 2 FIRST MI Total pages filed: OFFICE USE ONLY Date Received ○ ○ ○ ○ ○ STATE; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ CITY; ○ ○ ○ ○ ○ ○ APT / SUITE #; SUFFIX ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ADDRESS / PO BOX; 4 LAST ○ NICKNAME ○ FORMER SPEAKER CANDIDATE NAME ACCOUNT # 1 See SPK-UC I NSTRUCTION GUIDE for detailed instructions. 1-800-325-8506 ZIP CODE FORMER SPEAKER CANDIDATE MAILING ADDRESS Date Hand-delivered or Date Postmarked Receipt # 5 FORMER SPEAKER CANDIDATE TELEPHONE NUMBER 6 AREA CODE ( PHONE NUMBER Date Processed ) Month Date Imaged Day Year PERIOD COVERED 7 EXTENSION Amount Month Day Year THROUGH VERIFICATION I swear, or affirm, that the accompanying report is true and correct and includes all information required to be reported by me under Chapter 302, Texas Government Code. Signature of Former Speaker Candidate 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 Printed name of officer administering oath Title of officer administering oath GO TO SCHEDULE A Printed on recycled paper Revised 01/12/2004 American LegalNet, Inc. www.USCourtForms.com Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 FORMER SPEAKER CANDIDATE REPORT OF UNEXPENDED CONTRIBUTIONS FORM Full name of contributor ○ ○ ○ ○ ○ ○ ○ Zip Code ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Full name of contributor ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Zip Code ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Full name of contributor ○ ○ ○ ○ ○ ○ ○ Zip Code ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ Contributor address; ○ Date ○ ○ ○ Full name of contributor ○ ○ ○ ○ ○ ○ ○ Zip Code ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ Contributor address; ○ Date ○ ○ ○ Full name of contributor ○ ○ ○ ○ ○ ○ ○ Zip Code ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ Contributor address; ○ Date In-kind contribution description(if applicable) ○ City; In-kind contribution description(if applicable) Amount / Value of contribution ($) ○ Contributor address; In-kind contribution description(if applicable) Amount / Value of contribution ($) Zip Code In-kind contribution description(if applicable) Amount / Value of contribution ($) State; In-kind contribution description(if applicable) Amount / Value of contribution ($) City; Full name of contributor Date In-kind contribution description(if applicable) Amount / Value of contribution ($) ○ Contributor address; 8 ○ Date Contributor address; Amount / Value of contribution ($) ACCOUNT # ○ 6 7 Total pages Schedule A: 3 2 FORMER SPEAKER CANDIDATE NAME 5 A 1 See SPK-UC I NSTRUCTION GUIDE for detailed instructions. Date SPK-UC SCHEDULE CONTRIBUTIONS ○ ○ ○ 4 1-800-325-8506 ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Printed on recycled paper Revised 01/12/2004 American LegalNet, Inc. www.USCourtForms.com P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 FORMER SPEAKER CANDIDATE REPORT OF UNEXPENDED CONTRIBUTIONS SPK-UC SCHEDULE B FORM LOANS 1 Amount of Loan ($) 5 6 First reporting ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ City; State; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Amount of Payment(s) Zip Code Source of Payment(s) 13 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ (continue at right) (go to next loan or schedule) Amount of Loan ($) Previously reported but still unpaid Names of responsible parties, other than former speaker candidate ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ City; State; Zip Code Source of Payment(s) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ (continue at right) ○ ○ ○ No ○ Yes Amount of Payment(s) ○ Addresses of responsible parties, other than former speaker candidate: Address; Payment(s) made on note ○ Zip Code ○ State; ○ City; ○ ○ ○ Name of lender Lender address; Paid during period covered by this report ○ ○ First reporting ○ ○ Date of loan ○ ○ No ○ Yes ○ 12 ○ Payment(s) made on note ○ Addresses of responsible parties, other than former speaker candidate: Address; 11 ○ 10 ○ Zip Code ○ State; ○ City; ○ Lender address; Names of responsible parties, other than former speaker candidate 9 ○ 8 by this report ○ Name of lender Paid during period covered still unpaid 7 Previously reported but ○ Date of loan ACCOUNT # ○ 4 NAME ○ FORMER SPEAKER CANDIDATE Total pages Schedule B: 3 See SPK-UC INSTRUCTION GUIDE for detailed instructions. 2 1-800-325-8506 ○ Texas Ethics Commission (go to next loan or schedule) ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Printed on recycled paper Revised 01/12/2004 American LegalNet, Inc. www.USCourtForms.com ○ ○ ○ Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 FORMER SPEAKER CANDIDATE REPORT OF UNEXPENDED CONTRIBUTIONS 1-800-325-8506 FORM SPK-UC SCHEDULE EXPENDITURES C See SPK-UC I NSTRUCTION GUIDE for detailed instructions. FORMER SPEAKER CANDIDATE 3 ACCOUNT # ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Payee address; ○ 6 7 Payee name 5 Date NAME ○ 4 Total pages Schedule C: Amount ($) ○ 2 1 Zip Code ○ 8 Purpose of expenditure Payee name Amount ($) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Payee address; ○ Date Zip Code Purpose of expenditure Payee name Amount ($) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Payee address; ○ Date Zip Code Purpose of expenditure Payee name Amount ($) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ State; ○ ○ ○ ○ City; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Payee address; ○ Date Zip Code Purpose of expenditure ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Printed on recycled paper Revised 01/12/2004 American LegalNet, Inc. www.USCourtForms.com