Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 1-800-325-8506 SPEAKER CONTRIBUTION ACCOUNT AFFIDAVIT TITLE NAME, ADDRESS, & TELEPHONE NUMBER OF INDIVIDUAL WHO OPENED THIS ACCOUNT FIRST MI OFFICE USE ONLY TEC Account Number ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ LAST ○ ○ ○ ○ ○ NICKNAME SUFFIX Date Received ○ ○ ○ ○ ○ ○ ZIP CODE ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PHONE NUMBER ○ STATE; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ AREA CODE CITY; ○ APT / SUITE #; ○ ADDRESS / PO BOX; EXTENSION Date Hand-delivered or Date Postmarked ( NAME & ADDRESS OF FINANCIAL INSTITUTION ) FINANCIAL INSTITUTION Date Processed Date Imaged ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ STATE; ○ ○ ○ CITY; ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ADDRESS / PO BOX; ZIP CODE ACCOUNT NUMBER ISSUED BY FINANCIAL INSTITUTION I hereby swear and affirm that I have opened the account referenced above for the purpose of using funds in the account to make contributions to a candidate for Speaker of the Texas House of Representatives. I further swear and affirm that the funds deposited in this account consist only of political contributions accepted by me, and that none of the political contributions contained in this account were contributed to me by a committee, including a political committee, or by a corporation, partnership, association, firm, union, foundation, club, or other organization or group of persons, or from an elected officer or employee of the executive or judicial branch of state government. Signature of Individual Opening Account NOTARY STAMP / SEAL Sworn to and subscribed before me by ________________________________________________________ on this the __________________________ day of _______________________________, 20______________, to certify which, witness my hand and seal of office. Signature of officer administering oath Printed on recycled paper Print name of officer administering oath Title of officer administering oath (Revised 06/18/2002) American LegalNet, Inc. www.USCourtForms.com