Revised//201 Form provided byTexas Ethics Commission www.ethics.state.tx.usOFFICE USE ONLY Docket NumberDate Hand-delivered or Date Postmarked8GO TO PAGE 2 RESPONDENTPHYSICALADDRESS (Full home or business address, including street, city, state, and zip code)ADDRESSAPT /SUITE #CITYSTATEZIP CODE 11RESPONDENTTELEPHONENUMBERAREA CODE PHONE NUMBER EXTRESPONDENTE-MAIL ADDRESS10(REQUIRED IF KNOWN) (REQUIRED)9RESPONDENTMAILINGADDRESSADDRESSAPT /SUITE # CITYSTATEZIP CODE(Full street or mailing address, including city, state, and zip code)(check if same as above) (REQUIRED)000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 NICKNAMELASTSUFFIXCOMPLAINANTNAME I.IDENTITY OF COMPLAINANTMS / MRS / MRFIRSTMICOMPLAINANTTELEPHONENUMBERCOMPLAINANTE-MAILADDRESS5 AREA CODE PHONE NUMBEREXT (REQUIRED)(REQUIRED)(REQUIRED)COMPLAINANTPHYSICALADDRESS(check if same as above)COMPLAINANTMAILINGADDRESS ADDRESSAPT/ SUITE #CITYSTATEZIP CODEADDRESSAPT/ SUITE #CITYSTATEZIP CODE(Full home or business address, including street, city, state, and zip code)(Full street or mailing address, including city, state, and zip code) (REQUIRED)7RESPONDENTPOSITION ORTITLE(REQUIRED)000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000(REQUIRED)NICKNAMELASTSUFFIX(REQUIRED IF KNOWN)1423 II.IDENTITY OF RESPONDENT6RESPONDENTNAMEMS / MRS / MRFIRSTMISWORN COMPLAINT BEFORE THE TEXAS ETHICS COMMISSIONSection 571.122 of the Government Code requires that a sworn complaint be filed on a form prescribedby the Texas Ethics Commission and include specific information.225mustcomplete a separate sworncomplaintformforeach respondent225a violation ofa law thatis within tTexasEthicsCommission'sjurisdictiocan be found athttps://www.ethicsstate.tx.us/tec/sworn.html.225Please completely fill out this form.Failure to complete this form properly will cause yourcomplaint to be noncompliant and returned.(if unknown, please state that) American LegalNet, Inc. www.FormsWorkFlow.com Revised/201 Form provided byTexas Ethics Commission www.ethics.state.tx.us Includethespecificlaw(s)orrule(s)allegedtohavebeenviolated.AVIOLATIONOFALAWTHATISWITHINTHECOMMISSION'SJURISDICTION.TheTexasEthicsCommissionhasjurisdictiontoenforceonlythefollowing laws: (1) Title 15 of the Election Code; (2) Chapters 302, 303, 305, 572 2004 of the Gov't Code; (3) 247 334.025 and247 335.055 of the Local Gov't Code; (4) Chapter 159 of the Local Gov't Code, in connection with a county judicialofficerwho elects to file a financial statement with the commission; and (5) 247 2152.064 and 247 2155.003 of the Gov't Code.Please completely fill out this form.Failure to complete this form properly will cause your complaint to benocompliant and returned.III.NATURE OF ALLEGED VIOLATIONPage 2 ATTACH ADDITIONAL PAGES AS NEEDED American LegalNet, Inc. www.FormsWorkFlow.com Revised Form provided byTexas Ethics Commission www.ethics.state.tx.us IV.STATEMENT OF FACTSPage 3 ATTACH ADDITIONAL PAGES AS NEEDEDYou must state the facts constituting the alleged violation(s), including the dates on which or theperiodoftimeinwhichtheallegedviolation(s)occurred.Identifyallegationsoffactnotpersonallyknownto,butallegedoninformationandbelief.sesimple, concise,anddirect statements. You must state facts that, if true, would constitute a violation of a lawwithintheCommission'sjurisdictionandallegefactstosufficientlyindicatethe mannerandmeansbywhich each alleged violation occurred.Please completely fill out this form.Failure to complete this form properly will cause your complaint to be noncompliant and returned. American LegalNet, Inc. www.FormsWorkFlow.com Revised Form provided byTexas Ethics Commission www.ethics.state.tx.us V.LISTING OF DOCUMENTS AND OTHER MATERIALSPage 4 ATTACH ADDITIONAL PAGES AS NEEDED You must list all documents and other materials filed with this complaint. Additionally, list all otherdocuments and other materials that are relevant to this complaint and that are within yourknowledge, including their location, if known. Relevant documents that are available to you or inyour possession must be included.Please completely fill out this form.Failure to complete this form properly will cause your complaint to be noncompliant and returned. American LegalNet, Inc. www.FormsWorkFlow.com Revised Form provided byTexas Ethics Commission www.ethics.state.tx.us AFFIX NOTARY STAMP / SEAL ABOVE(Execute this affidavit if the acts alleged are within your direct personal knowledge.)VI. AFFIDAVITPage 5 AFFIX NOTARY STAMP / SEAL ABOVE I, , complainant,swear that I am a resident of the state of Texas. I swear that I have reason to believeand do believe that the violation alleged in this complaint has occurred. The sourceof my information and belief is (state below): Signature of Complainant BASED ON PERSONAL KNOWLEDGE Please completely fill out this form.Failure to complete this form properly will cause your complaint to be noncompliant and returned.(Complainant)Sworn to and subscribed before me, by the said, this theday of, 20 , to certify which, witness my hand and seal of office. Sworn to and subscribed before me, by the said, this theday of Signature of officer administering oathTitle of officer administering oathPrinted name of officer administering oathBASED ON INFORMATION AND BELIEFVII. AFFIDAVIT(Execute this affidavit if the acts alleged are not within your direct personal knowledge, but are based on reasonable belief.)Title of officer administering oathPrinted name of officer administering oath Signature of officer administering oath Signature of ComplainantI, , complainant,swear that I am a resident of the state of Texas. I swear that I have knowledge of thefacts alleged in this complaint and that the information contained in this complaint istrue and correct., 20(Complainant), to certify which, witness my hand and seal of office. American LegalNet, Inc. www.FormsWorkFlow.com Texas driver's licensepersonal identification certificate(issued under Chapter 521 of theTransportation Code)commercial driver's license(issued under Chapter 522 of theTransportation Code)utility bill *bank statement *government check * ********************************************************************************** paycheck *other government document *property tax bill, notice of appraised value, or other government document thatshows the address ofeal property in Texas,and identifies as the owner of the real property.Revised Form provided byTexas Ethics Commission www.ethics.state.tx.us**********************************************************************************ACOMPLAINTWILLBEIFACOPYOFONEOFTHEFOLLOWINGDOCUMENTSISNOTATTACHEDASPROOFOFTEXASRESIDENCYOROWNERSHIPOFREALPROPERTYINTEXAS.Pleasecheckoneoftheboxesbelowtoindicatethetypeofdocumentyouhaveattachedtothecomplaint:mayalsobeeligibletofileasworncomplaintwiththeTexasEthicsCommissionifrealpropertyinthestate of Texas. Under this provision, required to attach to the complaint a copy of aproperty tax bill, notice ofappraisedvalue,orothergovernmentdocumentthatshowstheaddressofrealpropertyinTexas, and identifies as the owner of the real property.must be a resident of the state of Texas to be eligible to file a sworn complaint with the Texas EthicsCommission.required to attach to the complaint a copy of one of the following documents:225complainant's driver's license or personal identification certificate issued under Chapter 521 of theTransportation Code, or commercial driver's license issued under Chapter 522 of the TransportationCode; or225a utility bill, bank statement, government check, paycheck or other government document that shows thename and address of the complainant and is dated not more than 30 days before the date on which thecomplaint is filed.*withnameandaddressanddatednotmorethan30daysbeforethedateonwhichthecomplaintisfiled***********************************************************************************(2)handdelivery to 201E.14th Street, Sam Houston Building, 10thloor, Austin, Texas78701, or(3)to. 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