Yes! S-PAC - Treasurer's Appointment - 10-18-16Texas Ethics Commission
P.O. Box 12070
Austin Texas 78711 -
(TDD 1-800-735 2989
---- .-._, .--., '-'
APPOINTMENT OF A CAMPAIGN TREASURER FORM STA
BY A SPECIFIC -PURPOSE COMMITTEE PG 1
See STA Instruction Guide for detailed instructions.
1 Total pages filed: (*
2 COMMITTEE
NAME
tI
" ��•
USE ONLY
Acct.#
3 COMMITTEE
ADDRESS
ADDRESS/POBOX, APT /SUITE CITY; STATE, ZIP CODE
2
Date Received
410 I -b 1<bl'N
6.0-
ag Desk` L lic >
4 CAMPAIGN
TREASURER
NAME
MS/MRS/MR FIRST MI
tt.
NICKNAME LAST r0 SUFFIX
H/v JaN)
HD/• I
5 CAMPAIGN
TREASURER
STREET
ADDRESS
(residence or business)I
STREET ADDRESS (NO PO BOX PLEASE), APT / SUITE #, CITY; STATE; ZIP CODE
I
, )0/1.q
I
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D.teP :- sse•
Too
T /o�I J1(4,
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0 10 16
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6 MAILING
ADDRESS
same as above
ADDRESS / PO BOX; APT / SUITE it; CITY; STATE, ZIP CODE
,A
S EL—K1 t'›LP*.E.1 S (
.- ' �✓ 1","). 17340
7 CAMPAIGN
TREASPHONE URER
AREA CODE PHONE NUMBER EXTENSION
( Z'k) 2-01 —4352---
8 PERSON
TRN APPOINTING
TREASURER
FIRST MI LAST SUFFIX
- `�
1"'sd
9 SIGNATURE
I understand that I have been appointed as the campaign treasurer
committee and that I am responsible for filing all required reports
to fines for failure to do so. I am aware of the restrictions in title
contributions from corporations and labor organization
for this specific -purpose
and that I may be subject
15 of the Election Code on
Signature of Ca - . Treasurer
10 ASSISTANT
CAMPAIGN
TREASURER
(see instructions)
FIRST MI LAST SUFFIX
11 ASSISTANT
CAMPAIGN
TREASURER
ADDRESS
ADDRESS /PO BOX; APT/SUITE#; CITY; STATE; ZIP CODE
12 ASSISTANT
CAMPAIGN
TREASURER
PHONE
AREA CODE PHONE NUMBER EXTENSION
( )
\ /
CONTINUE ON PAGE 2
www.ethics.state.tx. us
Revised 09/04/2014
•
Austin Texas 78711-2070
512) 463-5800
(TDD 1-800-735-2989)
ICAcdJ CU uw IJun U 1 ',aaw,, . .v......... .�... .. ,
SPECIFIC -PURPOSE COMMITTEE: FORM STA
PURPOSE AND MODIFIED REPORTING DECLARATION PG 2
13 COMMITTEE NAME�1
i,
yes
14 COMMITTEE
PURPOSE
SUPPORT CANDIDATE
CANDIDATE/OFFICEHOLDER NAME
I I OPPOSE CANDIDATE
I I ASSIST OFFICEHOLDER
OFFICE SOUGHT (candidate) / OFFICE HELD (officeholder)
c. ----
SUPPORT MEASURE
BALLOT IDENTIFICATION OF MEASURE / #
�CZ,6?S l J I. A -
ELECTION DATE
Month / Day Year
i k / T:5--/ it.1
1 IOPPOSE MEASURE
DESCRIPTION
Ch 40FrzzPe 5Mor.1
15 MODIFIED
REPORTING
DECLARATION
1"//�
COMPLETE THIS SECTION ONLY IF YOU ARE CHOOSING
MODIFIED REPORTING.
••This declaration must be filed no later than the 30th day
before the first election to which the declaration applies. •-
••The modified reporting declaration is valid for one election cycle only.
(An election cyde indudes a primary election, a general election, and any related runoffs.)
The committee does not intend to accept more than $500 in political
contributions or make more than $500 in political expenditures (excluding
filing fees) in connection with any future election within the election cycle.
The committee understands that if either one of those limits is exceeded,
the committee's campaign treasurer will be required to file pre-election
reports and, if necessary, a runoff report.
•-
,
Year of election(s) or election cycle to Signature of Campaign Treasurer
which declaration applies
ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED
www.ethics.state.tx.us
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