LEGISLATIVE CAUCUS REPORT OF CONTRIBUTIONS & EXPENDITURES The Form LEG Instruction Guide explains how to complete this form. 3 CAUCUS NAME FORM LEG COVER SHEET PG 1 1 Filer ID (Ethics Commission Filers) 2 Total pages filed: OFFICE USE ONLY Date Received 4 CAUCUS CHAIR MS / MRS / MR FIRST MI NICKNAME LAST SUFFIX 5 CAUCUS MAILING ADDRESS Address or P.O. Box; Apt/Suite # Change of Address City; State; Zip Code 6 REPORT TYPE January 15 July 15 7 PERIOD COVERED Month Day Year Month Day Year Date Imaged Through 8 NO REPORTABLE ACTIVITY 9 CONTRIBUTION TOTALS 1. Check here if the caucus has no reportable activity during this report period. (Sign below and submit this page only.) TOTAL CONTRIBUTIONS OF $50 OR LESS FROM NON-CAUCUS MEMBERS (Do Not Include Loan Information or Amounts Itemized on Schedule A(L)) 2. TOTAL CONTRIBUTIONS (Include Contributions from Caucus Members; Do Not Include Loan Information) EXPENDITURE TOTALS 3. TOTAL EXPENDITURES OF $50 OR LESS (Do Not Include Amounts Itemized on Schedule F(L)) 4. OUTSTANDING LOAN TOTALS TOTAL EXPENDITURES TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE LAST DAY OF THE REPORT PERIOD 5. 10 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the accompanying report is true and correct and includes all information required to be reported by me under Title 15, Election Code. Signature of Caucus Chair 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 Forms provided by Texas Ethics Commission www.ethics.state.tx.us Date Hand-delivered or Date Postmarked Receipt # Amount $ Date Processed $ $ $ $ $ Title of officer administering oath Revised 06/22/2015 American LegalNet, Inc. www.FormsWorkFlow.com SUBTOTALS - LEG 11 CAUCUS NAME FORM LEG COVER SHEET PG 2 12 Filer ID (Ethics Commission Filers) 13 SCHEDULE SUBTOTALS NAME OF SCHEDULE SCHEDULE A(L): NON-CAUCUS MEMBER CONTRIBUTIONS ITEMIZED CONTRIBUTIONS OTHER THAN LOANS SCHEDULE E(L): LOANS TO LEGISLATIVE CAUCUS LOAN AND GUARANTOR INFORMATION SCHEDULE F(L): LEGISLATIVE CAUCUS EXPENDITURES ITEMIZED EXPENDITURES SUBTOTAL AMOUNT 1. $ $ $ 2. 3. Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 06/22/2015 American LegalNet, Inc. www.FormsWorkFlow.com NON-CAUCUS MEMBER CONTRIBUTIONS ITEMIZED CONTRIBUTIONS OTHER THAN LOANS 1 The Instruction Guide explains how to complete this form. 2 CAUCUS NAME SCHEDULE A(L) (FOR FORM LEG) Total pages Schedule A(L): 3 Filer ID (Ethics Commission Filers) 4 Date 5 Full name of contributor 7 Amount of contribution ($) 8 In-kind contribution description (if applicable) 6 Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code Date Full name of contributor Contributor address; City; State; Zip Code ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 06/22/2015 Amount of contribution ($) In-kind contribution description (if applicable) Amount of contribution ($) In-kind contribution description (if applicable) Amount of contribution ($) In-kind contribution description (if applicable) Amount of contribution ($) In-kind contribution description (if applicable) Amount of contribution ($) In-kind contribution description (if applicable) American LegalNet, Inc. www.FormsWorkFlow.com LOANS TO LEGISLATIVE CAUCUS LOAN AND GUARANTOR INFORMATION The Instruction Guide explains how to complete this form. SCHEDULE E(L) (FOR FORM LEG) 1 Total pages Schedule E(L): 2 CAUCUS NAME 3 Filer ID (Ethics Commission Filers) 4 TOTAL OF UNITEMIZED LOAN: 5 Date of loan $ 9 Loan Amount ($) 7 Name of lender 6 Is lender a financial Institution? 8 Lender address; City; State; Zip Code Y N 12 Description of Collateral None 13 GUARANTOR INFORMATION 14 Name of guarantor 15 Guarantor address; City; Not Applicable State; Zip Code 17 Principal Occupation 18 Employer Date of loan Name of lender Is lender a financial Institution? Lender address; City; State; Zip Code Y N Description of Collateral None GUARANTOR INFORMATION Name of guarantor Guarantor address; Not Applicable City; State; Zip Code Principal Occupation Employer ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 06/22/2015 10 Interest rate 1 Maturity date 1 16 Amount Guaranteed ($) Loan Amount ($) Interest rate Maturity date Amount Guaranteed ($) American LegalNet, Inc. www.FormsWorkFlow.com LEGISLATIVE CAUCUS EXPENDITURES ITEMIZED EXPENDITURES The Instruction Guide explains how to complete this form. 2 CAUCUS NAME 1 SCHEDULE F(L) (FOR FORM LEG) Total pages Schedule F(L): 3 Filer ID (Ethics Commission Filers) 4 Date 5 Payee name 7 Amount ($) 6 Payee address; City; State; Zip Code 8 Purpose of expenditure (See instructions regarding type of information required.) Date Payee name Payee address; City; State; Zip Code Purpose of expenditure (See instructions regarding type of information required.) Date Payee name Payee address; City; State; Zip Code Purpose of expenditure (See instructions regarding type of information required.) Date Payee name Payee address; City; State; Zip Code Purpose of expenditure (See instructions regarding type of information required.) ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 06/22/2015 Amount ($) Amount ($) Amount ($) American LegalNet, Inc. www.FormsWorkFlow.com