Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) GOVERNOR FOR A DAY REPORT FORM GOV-D COVER SHEET OFFICE USE ONLY See the next page for information about the law regarding the Governor for a Day Report. Account # Date Received 1 TOTAL PAGES OF SCHEDULE A FILED: TOTAL PAGES OF SCHEDULE B FILED: Date Hand-delivered or Postmarked 2 CHAIRMAN'S NAME TITLE FIRST MI Receipt # Amount NICKNAME LAST SUFFIX Date Processed Date Imaged 3 CHAIRMAN'S MAILING ADDRESS STREET OR PO BOX APT / SUITE # CITY STATE ZIP CODE 4 CHAIRMAN'S TELEPHONE NUMBER AREA CODE TELEPHONE NUMBER EXTENSION ( ) 5 REPORT TYPE FINAL REPORT SUPPLEMENTAL REPORT IF THIS IS A FINAL REPORT, IS THERE AN OUTSTANDING DEBT ON THE DATE OF THIS REPORT? YES NO 6 DATE OF CEREMONY MONTH DAY YEAR 7 CONTRIBUTION TOTALS A. TOTAL CONTRIBUTIONS FROM SCHEDULE A B. TOTAL CONTRIBUTIONS OF $50 OR LESS C. TOTAL OF ALL CONTRIBUTIONS (ADD LINES 7A & 7B) $ $ $ $ $ $ 8 EXPENDITURE TOTALS A. TOTAL EXPENDITURES FROM SCHEDULE F B. TOTAL EXPENDITURES OF $50 OR LESS C. TOTAL OF ALL EXPENDITURES (ADD LINES 8A & 8B) Signature of Chairman www.ethics.state.tx.us Revised 03/09/2007 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) GOVERNOR FOR A DAY REPORT FORM GOV-D GOVERNOR FOR A DAY CEREMONY. Government Code chapter 303 regulates contributions and expenditures for a Governor for a Day ceremony. DESIGNATION OF CHAIRMAN. Before any contributions are accepted or any expenditures are made for a Governor for a Day ceremony, the President Pro Tempore shall designate a chairman to be responsible for conducting the ceremony. The chairman is responsible for keeping the records and filing the reports required by Government Code chapter 303. REQUIRED REPORTS. Final Report: Not later than the 60th day after the date of the Governor for a Day ceremony, the chairman shall file with the Texas Ethics Commission a final report of contributions and expenditures. Supplemental Report: If there is an outstanding debt when the final report is filed, the chairman shall file a supplemental report of contributions and expenditures not later than the 30th day after the date on which the debt is retired. REPORTING CONTRIBUTIONS. Complete Schedule A for each individual or entity that contributed more than $50. Enter the aggregate total of contributions reported on Schedule A on Line 7A of the Cover Sheet. Enter the aggregate total of contributions from individuals or entities that contributed $50 or less on Line 7B of the Cover Sheet. Add Lines 7A and 7B to calculate total contributions and enter that amount on Line 7C of the Cover Sheet. REPORTING EXPENDITURES. Complete Schedule F for each expenditure of more than $50. Enter the aggregate total of expenditures reported on Schedule F on Line 8A of the Cover Sheet. Enter the aggregate total of expenditures of $50 or less on Line 8B of the Cover Sheet. Add Lines 8A and 8B to calculate total expenditures and enter that amount on Line 8C of the Cover Sheet. SURPLUS FUNDS. If each obligation has been paid at the end of the 60-day period and there is an outstanding balance, the chairman shall: (1) distribute the balance to one or more charities designated by the president pro tempore or speaker; or (2) retain the balance in an account established for that purpose in the name of the office of the president pro tempore or speaker, as appropriate. If the outstanding balance is retained under Subsection (c)(2), the account balance shall be combined with contributions received for the succeeding governor for a day or speaker's reunion day ceremony, as appropriate, and may be spent only for the purposes provided by Section 303.004. www.ethics.state.tx.us Revised 03/09/2007 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) CONTRIBUTIONS (Complete Schedule A for any individual or entity whose total contributions exceed $50.) 1 Total pages Schedule A (GOV): 2 Chairman's name SCHEDULE A (GOV) OFFICE USE ONLY 3 Date 4 Full name of contributor 6 Amount of contribution ($) 7 Type of contribution 5 Contributor address; Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED www.ethics.state.tx.us Revised 03/09/2007 American LegalNet, Inc. www.FormsWorkFlow.com City; State; Zip Code cash contribution in-kind contribution Amount of contribution ($) Type of contribution cash contribution in-kind contribution Amount of contribution ($) Type of contribution cash contribution in-kind contribution Amount of contribution ($) Type of contribution cash contribution in-kind contribution Amount of contribution ($) Type of contribution cash contribution in-kind contribution Amount of contribution ($) Type of contribution cash contribution in-kind contribution Amount of contribution ($) Type of contribution cash contribution in-kind contribution Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) EXPENDITURES (Complete Schedule F for expenditures of more than $50.) 1 Total pages schedule F (GOV): SCHEDULE F (GOV) OFFICE USE ONLY 2 Chairman's name 3 Date 4 Payee name 6 Amount ($) 5 Payee address; City; State; Zip Code 7 Purpose of expenditure Date Payee name Payee address; City; State; Zip Code Purpose of expenditure Date Payee name Payee address; City; State; Zip Code Purpose of expenditure Date Payee name Payee address; City; State; Zip Code Purpose of expenditure ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED www.ethics.state.tx.us Revised 03/09/2007 American LegalNet, Inc. www.FormsWorkFlow.com Amount ($) Amount ($) Amount ($)