STATE / COUNTY CHAIR SPECIFIC-PURPOSE COMMITTEE CAMPAIGN FINANCE REPORT The SC SPAC Instruction Guide explains how to complete this form. 3 COMMITTEE NAME COMMITTEE ADDRESS Change of Address STREET ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE FORM SC SPAC COVER SHEET PG 1 1 Filer ID (Ethics Commission Filers) 2 Total pages filed: OFFICE USE ONLY Date Received 4 5 MS / MRS / MR FIRST MI NICKNAME LAST SUFFIX 6 CAMPAIGN TREASURER STREET ADDRESS (Residence or Business) STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; ZIP CODE 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 convention \ election 8th day before convention \ election Runoff Dissolution (Attach SC SPAC-DR) 10th day after campaign treasurer termination 9 REPORT TYPE 10 PERIOD COVERED Month Day Year THROUGH 1 CONVENTION / 1 ELECTION DATE 12 POLITICAL PARTY Month Day Year 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 CAMPAIGN TREASURER NAME Date Hand-delivered or Date Postmarked Receipt # Amount $ Date Processed ZIP CODE Month Day Year STATE / COUNTY CHAIR SPECIFIC-PURPOSE COMMITTEE REPORT: PURPOSE AND TOTALS 13 COMMITTEE NAME FORM SC SPAC COVER SHEET PG 2 14 Filer ID (Ethics Commission Filers) 15 COMMITTEE PURPOSE (Attach lists on plain paper to complete this report if necessary.) OFFICE SOUGHT STATE CHAIR COUNTY CHAIR COUNTY NAME SUPPORT OPPOSE CANDIDATE NAME 16 CONTRIBUTION TOTALS 1. TOTAL POLITICAL CONTRIBUTIONS OF $50 OR LESS (OTHER THAN LEDGES, 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. TOTAL POLITICAL EXPENDITURES TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY OF THE REPORTING PERIOD CONTRIBUTION BALANCE OUTSTANDING LOAN TOTALS 5. 6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE LAST DAY OF THE REPORTING PERIOD 17 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 Campaign Treasurer 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 SPAC 18 COMMITTEE NAME FORM SC SPAC COVER SHEET PG 3 19 Filer ID (Ethics Commission Filers) 20 SCHEDULE SUBTOTALS NAME OF SCHEDULE SCHEDULE A1: MONETARY POLITICAL CONTRIBUTIONS SCHEDULE A2 : NON-MONETARY (IN-KIND) POLITICAL CONTRIBUTIONS SCHEDULE B: PLEDGED CONTRIBUTIONS 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 SCHEDULE F4: EXPENDITURES MADE BY CREDIT CARD SCHEDULE H: PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH SUBTOTAL AMOUNT 1. $ $ $ $ $ $ $ $ $ $ 2. 3. 4. 5. 6. 7. 8. 9. 10. SCHEDULE I: NON-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS 11. 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 (if any) (FOR JUDICIAL) 16 If contributor is a child, law firm of parent(s) (if any) (FOR JUDICIAL) Date Full name of contributor out-of-state PAC (ID#:______________________) Amount of Contribution $ In-kind contribution description Contributor address; City; State; Zip Code Check if travel outside of Texas. Complete Schedule T. Principal occupation / Job title (FOR NON-JUDICIAL) (See Instructions) Employer (FOR NON-JUDI