SPECIFIC-PURPOSE COMMITTEE CAMPAIGN FINANCE REPORT 1 The SPAC Instruction Guide explains how to complete this form. 3 COMMITTEE NAME Filer ID (Ethics Commission Filers) FORM SPAC COVER SHEET PG 1 2 Total pages filed: OFFICE USE ONLY Date Received 4 COMMITTEE ADDRESS Change of Address ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE Date Hand-delivered or Date Postmarked 5 CAMPAIGN TREASURER NAME MS / MRS / MR FIRST MI Receipt # Amount $ Date Processed Date Imaged NICKNAME LAST SUFFIX 6 CAMPAIGN TREASURER STREET ADDRESS (Residence or Business) STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; 7 CAMPAIGN TREASURER MAILING ADDRESS Change of Address STREET ADDRESS OR PO BOX; APT / SUITE #; CITY; STATE; 8 CAMPAIGN TREASURER PHONE AREA CODE PHONE NUMBER EXTENSION ( ) January 15 July 15 30th day before election 8th day before election Runoff Exceeded $500 limit Dissolution (Attach PAC-DR) 10th day after campaign treasurer termination 9 REPORT TYPE 10 PERIOD COVERED Month Day Year THROUGH 1 ELECTION 1 Month ELECTION DATE Day Year Primary General Runoff Special ELECTION TYPE Other Description GO TO PAGE 2 Forms provided by Texas Ethics Commission www.ethics.state.tx.us ZIP CODE ZIP CODE Month Day Year Revised 9/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com SPECIFIC-PURPOSE COMMITTEE REPORT: PURPOSE AND TOTALS 12 COMMITTEE NAME FORM SPAC COVER SHEET PG 2 13 Filer ID (Ethics Commission Filers) 14 COMMITTEE PURPOSE (Attach lists on plain paper to complete this report if necessary.) CANDIDATE / OFFICEHOLDER NAME CANDIDATE SUPPORT (Candidate or Measure) OFFICEHOLDER OFFICE SOUGHT (candidate) / OFFICE HELD (officeholder) OPPOSE (Candidate or Measure) BALLOT IDENTIFICATION / # ELECTION DATE Month Day Year ASSIST (Officeholder) MEASURE DESCRIPTION 15 CONTRIBUTION TOTALS 1. TOTAL POLITICAL CONTRIBUTIONS OF $50 OR LESS (OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS), UNLESS ITEMIZED $ $ $ $ 2. EXPENDITURE TOTALS TOTAL POLITICAL CONTRIBUTIONS (OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS) 3. 4. TOTAL POLITICAL EXPENDITURES OF $100 OR LESS, UNLESS ITEMIZED TOTAL POLITICAL EXPENDITURES CONTRIBUTION BALANCE OUTSTANDING LOAN TOTALS 16 AFFIDAVIT 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 Forms provided by Texas Ethics Commission 5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY OF THE REPORTING PERIOD $ $ 6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE LAST DAY OF THE REPORTING PERIOD 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 Campaign Treasurer Printed name of officer administering oath Title of officer administering oath www.ethics.state.tx.us Revised 9/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com SUBTOTALS - SPAC 17 COMMITTEE NAME FORM SPAC COVER SHEET PG 3 18 Filer ID (Ethics Commission Filers) 19 SCHEDULE SUBTOTALS NAME OF SCHEDULE SCHEDULE A1: MONETARY POLITICAL CONTRIBUTIONS SCHEDULE A2 : NON-MONETARY (IN-KIND) POLITICAL CONTRIBUTIONS SUBTOTAL AMOUNT 1. $ $ $ $ $ $ $ $ $ $ $ $ $ 2. 3. 4. 5. 6. SCHEDULE B: PLEDGED CONTRIBUTIONS SCHEDULE C1: MONETARY CONTRIBUTIONS FROM CORPORATION OR LABOR ORGANIZATION SCHEDULE C2 : NON-MONETARY (IN-KIND) CONTRIBUTIONS FROM CORPORATION OR LABOR ORGANIZATION SCHEDULE D: PLEDGED CONTRIBUTIONS FROM CORPORATON OR LABOR ORGANIZATION 7. 8. SCHEDULE E: LOANS SCHEDULE F1: POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS SCHEDULE F2: UNPAID INCURRED OBLIGATIONS SCHEDULE F3: PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS 9. 10. 11. 12. SCHEDULE F4: EXPENDITURES MADE BY CREDIT CARD SCHEDULE H: PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH 13. SCHEDULE I: NON-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS 14. SCHEDULE K: INTEREST, CREDITS, GAINS, REFUNDS, AND CONTRIBUTIONS RETURNED TO FILER $ Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com MONETARY POLITICAL CONTRIBUTIONS The Instruction Guide explains how to complete this form. 2 FILER NAME SCHEDULE 1 Total pages Schedule A1: A1 3 Filer ID (Ethics Commission Filers) 4 Date 5 Full name of contributor out-of-state PAC (ID#:_______________________) 7 Amount of contribution ($) 6 Contributor address; City; State; Zip Code 8 Principal occupation / Job title (See Instructions) 9 Employer (See Instructions) Date Full name of contributor out-of-state PAC (ID#:_______________________) Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) Date Full name of contributor out-of-state PAC (ID#:_______________________) Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) Date Full name of contributor out-of-state PAC (ID#:_______________________) Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED If contributor is out-of-state PAC, please see instruction guide for additional reporting requirements. Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com Amount of contribution ($) Amount of contribution ($) Amount of contribution ($) NON-MONETARY (IN-KIND) POLITICAL CONTRIBUTIONS The Instruction Guide explains how to complete this form. 2 FILER NAME SCHEDULE A2 1 Total pages Schedule A2: 3 Filer ID (Ethics Commission Filers) 4 TOTAL OF UNITEMIZED IN-KIND POLITICAL CONTRIBUTIONS 5 Date 6 Full name of contributor $ 8 Amount of Contribution $ out-of-state PAC (ID#:______________________) 9 In-kind contribution description 7 Contributor address; City; State; Zip Code Check if travel outside of Texas. Complete Schedule T. 10 Principal occupation / Job title (FOR NON-JUDICIAL) (See Instructions) 12 Contributor's principal occupation (FOR JUDICIAL) 14 Contributor's employer/law firm (FOR JUDICIAL) 1 1 Employer (FOR NON-JUDICIAL) (See Instructions) 13 Contributor's job title (FOR JUDICIAL) (See Instructions) 15 Law firm of contributor's spouse