STATE / COUNTY CHAIR CAMPAIGN FINANCE REPORT 1 Filer ID The SC C/OH Instruction Guide explains how to complete this form. 3 CANDIDATE NAME FORM SC C/OH COVER SHEET PG 1 2 Total pages filed: (Ethics Commission Filers) MS / MRS / MR FIRST MI OFFICE USE ONLY OFFICE USE ONLY NICKNAME LAST SUFFIX Date Received 4 CANDIDATE ADDRESS Change of Address ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE 5 CANDIDATE PHONE AREA CODE PHONE NUMBER EXTENSION ( ) FIRST MI Date Hand-delivered or Date Postmarked 6 CAMPAIGN TREASURER NAME MS / MRS / MR Receipt # NICKNAME LAST SUFFIX Amount $ Date Imaged Date Processed 7 CAMPAIGN TREASURER ADDRESS STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; ZIP CODE (Residence or Business) 8 CAMPAIGN TREASURER PHONE AREA CODE PHONE NUMBER EXTENSION ( ) January 15 30th day before convention / election Runoff 9 REPORT TYPE July 15 8th day before convention / election Final report (Attach SC C/OH - FR) 10 PERIOD COVERED Month Day Year Month Day Year THROUGH 1 CONVENTION / 1 ELECTION DATE Month Day Year 12 OFFICE SOUGHT STATE CHAIR COUNTY CHAIR 13 POLITICAL PARTY COUNTY (If Applicable) GO TO PAGE 2 Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com STATE / COUNTY CHAIR CAMPAIGN FINANCE REPORT 14 CANDIDATE NAME FORM SC C/OH COVER SHEET PG 2 15 Filer ID (Ethics Commission Filers) 16 NOTICE FROM POLITICAL COMMITTEE(S) This box is for notice of political expenditures by political committees to support the candidate. These expenditures may have been made without the candidate's knowledge or consent. Candidates are required to report this information only if they receive notice of such expenditures. COMMITTEE TYPE COMMITTEE NAME GENERAL COMMITTEE ADDRESS SPECIFIC COMMITTEE CAMPAIGN TREASURER NAME Additional Pages COMMITTEE CAMPAIGN TREASURER ADDRESS 17 CONTRIBUTION TOTALS 1. TOTAL POLITICAL CONTRIBUTIONS OF $50 OR LESS (OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS), UNLESS ITEMIZED $ $ $ $ $ $ 2. TOTAL POLITICAL CONTRIBUTIONS (OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS) EXPENDITURE TOTALS 3. TOTAL POLITICAL EXPENDITURES OF $100 OR LESS, UNLESS ITEMIZED 4. CONTRIBUTION BALANCE OUTSTANDING LOAN TOTALS 18 AFFIDAVIT TOTAL POLITICAL EXPENDITURES 5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY OF THE REPORTING PERIOD TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE LAST DAY OF THE REPORTING PERIOD 6. 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 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 Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/1/2015 American LegalNet, Inc. www.FormsWorkFlow.com SUBTOTALS - SC C/OH 19. CANDIDATE NAME FORM SC C/OH COVER SHEET PG 3 20. Filer ID (Ethics Commission Filers) 21. 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 E: LOANS SCHEDULE F1: POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS SCHEDULE F2: UNPAID INCURRED OBLIGATIONS 7. 8. 9. 10. 11. SCHEDULE F3: PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS SCHEDULE F4: EXPENDITURES MADE BY CREDIT CARD SCHEDULE G: POLITICAL EXPENDITURES MADE FROM PERSONAL FUNDS SCHEDULE H: PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH SCHEDULE I: NON-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS SCHEDULE K: INTEREST, CREDITS, GAINS, REFUNDS, AND CONTRIBUTIONS RETURNED TO FILER 12. 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 (if any) (FOR JUDICIAL) 16 If contributor is a child, law firm of parent(s) (if any) (FOR