HERNANDEZ, ADRIAN_JANUARY 15 2019_CAMPAIGN FINANCE REPORT CANDIDATE / OFFICEHOLDER FORM C/OH
CAMPAIGN FINANCE REPORT COVER SHEET PG 1
1 Filer ID(Ethics Commission Filers) 2 Total pages filed: ' 1
The C/OH Instruction Guide explains how to complete this form.
3 CANDIDATE/ MS MRS/MR FIRST MI
OFFICEHOLDER Mr. Adrian M OFFICE USE ONLY
NAME
Date Received
NICKNAME LAST SUFFIX
Hernandez RECEIVE D
4 CANDIDATE/ ADDRESS /PO BOX; APT/SUITE#; CITY; STATE; ZIP CODE
OFFICEHOLDER JAN 16 2019
MAILING
ADDRESS Pearland, TX 77581 CITY OF PEARLAND
J Change of Address CITY SECRETARY'S OFF!CE
5 CANDIDATE/ AREA CODE PHONE NUMBER EXTENSION
OFFICEHOLDER Date Hand-delivered or Date Postmarked
PHONE ( \A6- 19
6 CAMPAIGN MS/MRS/MR FIRST MI Receipt# Amount$
TREASURER Mrs. Veronica K
NAME Date Processed
NICKNAME LAST SUFFIX
Longoria Date Ima e
7 CAMPAIGN STREET ADDRESS (NO PO BOX PLEASE); APT:SUITE#; CITY; STATE; ZIP CODE
TREASURER
ADDRESS
(Residence or Business) Pearland, TX 77584
8 CAMPAIGN AREA CODE PHONE NUMBER EXTENSION
TREASURER (
PHONE
9 REPORT TYPE
I XI January 15 I I 30th day before election I I Runoff I I 15th day after campaign
treasurer appointment
(Officeholder Only)
I I July 15 I 8th day before election I I Exceeded$500 limit I I Final Report(Attach C/OH-FR)
10 PERIOD Month Day Year Month Day Year
COVERED 07 / 16 2018THROUGH 01 / 15 / 2019
11 ELECTION ELECTION DATE ELECTION TYPE
Month Day Year ❑ Primary ❑ Runoff ❑ Other
Description
/ / I I General I I Special
12 OFFICE OFFICE HELD (if any) 13 OFFICE SOUGHT (if known)
City Council Position 4
City of Pearland, TX USA
GO TO PAGE 2
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
CANDIDATE / OFFICEHOLDER FORM C/OH
CAMPAIGN FINANCE REPORT COVER SHEET PG 2
14 C/OH NAME 15 Filer ID (Ethics Commission Filers)
Adrian M Hernandez
16 NOTICE FROM THIS BOX IS FOR NOTICE OF POLITICAL CONTRIBUTIONS ACCEPTED OR POLITICAL EXPENDITURES MADE BY POLITICAL COMMITTEES TO
POLITICAL SUPPORT THE CANDIDATE/OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATE'S OR OFFICEHOLDER'S
COMMITTEE(S) KNOWLEDGE OR CONSENT. CANDIDATES AND OFFICEHOLDERS ARE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY RECEIVE NOTICE
OF SUCH EXPENDITURES.
COMMITTEE TYPE COMMITTEE NAME
0 GENERAL
COMMITTEE ADDRESS
0 SPECIFIC
COMMITTEE CAMPAIGN TREASURER NAME
Additional Pages
COMMITTEE CAMPAIGN TREASURER ADDRESS
17 CONTRIBUTION 1. TOTAL POLITICAL CONTRIBUTIONS OF $50 OR LESS (OTHER THAN
TOTALS PLEDGES, LOANS, OR GUARANTEES OF LOANS), UNLESS ITEMIZED $
2. TOTAL POLITICAL CONTRIBUTIONS
(OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS) $ 3300.00
EXPETOTALS
3. TOTAL POLITICAL EXPENDITURES OF $100 OR LESS, $
UNLESS ITEMIZED
4. TOTAL POLITICAL EXPENDITURES $ 1107.45
CONTRIBUTION 5TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY
$ 2268.94
.BALANCEOF REPORTING PERIOD
OUTSTANDING 6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
LOAN TOTALS LAST DAY OF THE REPORTING PERIOD $ 0
18 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
DAISY MATHunder Title = -ction Code. "`��,`
( NOTAt
RYPUBUCSTATEOFTEXAS .
r MY COMMISSION EXPIRES
Expires:July 9.2019 ,
Notary ID N 12859425-2
i.nature of Ca .idate or Office der
AFFIX NOTARY STAMP/SEAL ABOVE ii
Sworn to and subscribed before me, by the said A(�(�Ar 1
' e • AFt(YVAY1CICZ ,this the I L
day of C)CW4 20 0 ,to certify which,witness my hand and seal of office.
Si to of officer administering oath Printed na of fficer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
SUBTOTALS - C/OH FORM C/OH
COVER SHEET PG 3
19 FILER NAME 20 Filer ID(Ethics Commission Filers)
Adrian M Hernandez
21 SCHEDULE SUBTOTALS SUBTOTAL
NAME OF SCHEDULE AMOUNT
1. X SCHEDULE A1: MONETARY POLITICAL CONTRIBUTIONS $ 3300.00
2. SCHEDULE A2: NON-MONETARY(IN-KIND)POLITICAL CONTRIBUTIONS $
3. SCHEDULE B: PLEDGED CONTRIBUTIONS $
4. ( SCHEDULE E: LOANS $
SCHEDULE Fl: POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS $ 1107.45
6. SCHEDULE F2: UNPAID INCURRED OBLIGATIONS $
7. SCHEDULE F3: PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS $
8. SCHEDULE F4: EXPENDITURES MADE BY CREDIT CARD $
9• SCHEDULE G: POLITICAL EXPENDITURES MADE FROM PERSONAL FUNDS $
10. SCHEDULE H: PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH $
11. SCHEDULE I: NON-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS $
12SCHEDULE K: INTEREST, CREDITS, GAINS, REFUNDS,AND CONTRIBUTIONS $
IX RETURNED TO FILER .36
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
MONETARY POLITICAL CONTRIBUTIONS SCHEDULE Al
The Instruction Guide explains how to complete this form. 1 Total pages Schedule Al: 3
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Adrian M Hernandez
4 Date 5 Full name of contributor 0 out-of-state PAC(ID#: ) 7 Amount of contribution ($)
48\30)E ?a-,2.IG,a 1010E1-2-
6 Contributor address; City; State; Zip Code 2.5-D. Ci.c)
€915 rArni rgwy (-tausTo,.) 1-% _62q(
styti
8 Principal occupation/Job title (See Instructions) g Employer (See Instructions)
G�'O 1..-M,01/40 OPJ LP
Date Full name of contributor 0 out-of-state PAC(ID#: l Amount of contribution ($)
e e-D C>zoo
9114) 1(8 Contributor address; City; State; Zip Code I
21026 UJoworc.t06E (� p on Vr. i�0 . U yr
D-kPr11-054-
Principal
incipal occupation/Job title (See Instructions) Employer (See Instructions)
C° SU- TA/yr Set-F
Date Full name of contributor 0 out-of-state PAC(IDn I Amount of contribution ($)
&R E q fTiZ 14outWO JJ 3 u.t-DE7LS Akss ex-,A.n o
V.0 S.A E -Pike
9( ! Contributor address; City; State; Zip Code
JIIB 5d v0
TSI 1 %.J. Sn�►,,. 44a�sco•� Pkv(. p.) v
liow.dcOt"i 1)C lcJM
Principal occupation/Job title(See Instructions) Employer (See Instructions)
PA c PA-C._
Date Full name of contributor ❑out-of-state PAC(ID#: I Amount of contribution ($)
Q ) A,L_-cat
Ito( i' Contributor address; City; State; Zip Code e CO ' c CD
11'46 &AeueNscrEsr (.1ou.Sc K) 1464-4 (.
Principal occupation/Job title (See Instructions) Employer (See Instructions)
Vito( D�),4-r E--)Q&--1 c s
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 9/8/2015
MONETARY POLITICAL CONTRIBUTIONS SCHEDULE Al
The Instruction Guide explains how to complete this form. 1 Total pages Schedule Al. 3
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Adrian M Hernandez
4 Date 5 Full name of contributor ❑out-of-state PAC(IDS: ) 7 Amount of contribution ($)
CLASS
)iOl l$ 6 Contributor address; City; State; Zip Code Sao OU
k S'sS weSrorric a Ow-
Ho t,-STO Ia 1 bka
8 Principal occupation/Job title (See Instructions) g Employer (See Instructions)
i \o P(2(IQC I toArc-
Date Full name of contributor ❑out-of-state PAC(105: i Amount of contribution ($)
Cs/AV Ts 12ow n)
q I La) Contributor address; City; State; Zip Code
/ 3 u-ittoy Dn. 2 �o " o 0
��8 140u.cTON/ TX, �acr► 8
Principal occupation/Job title (See Instructions) Employer (See Instructions)
&(.t LF- CPA5 T 412-1-14- eLbJ (, 0 t2 KS
Date Full name of contributor ❑out-of-state PAC(ID5: Amount of contribution ($)
r A 0N.LI G—r1vt�IP pAc
S11,QI 43 Contributor address; City; State; Zip Code
Z Z ipikr-FAt0 crElticA aCr 2 106
(-{okSTt> N , rx. PO IS
Principal occupation/Job title(See Instructions) Employer (See Instructions)
34 -Da194-c- 134 -
Date
te Full name of contributor ❑out-of-state PAC(IDS: i Amount of contribution ($)
P(ouE, AMN00r, Ft L_t,cwt CPU-s nt 5,4 07r srovENs Rp4A►.
q Ito/ (? Contributor address; City; State; Zip Code
111///
2A-IS � Vs Sco Sr 57) 0 (�v
P1/4) A.) , -f)( 51 c
Principal occupation/Job title(See Instructions) Employer (See Instructions)
trt. Gt4/x€55 0941-Dem POLP E P,(?Ar-OO/J FIELD CCALL.l4)( Nr tort LSP
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If contributor is out-of-state PAC,please see instruction guide for additional reporting requirements.
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
MONETARY POLITICAL CONTRIBUTIONS SCHEDULE Al
The Instruction Guide explains how to complete this form. 1 Total pages Schedule Al: 3
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Adrian M Hernandez
4 Date 5 Full name of contributor
❑out-of-stale PAC(ID#: ) 7 Amount of contribution ($)
i V)It c atptaN
II\tg) 6 Contributor address; City; State; Zip Code
I z- EAVu tNTI,N . (00 <
Ro v*Sr-o N , Tx -4-1003
8 Principal occupation/Job title (See Instructions) g Employer (See Instructions)
FL-+A4 O.A, - A M E021 c4? YLL(NES
Date Full name of contributor ❑out-of-state PAC(ID#: Amount of contribution ($)
r' PIA) GkAvA 1 ek
91244 ib Contributor address; City; State; Zip Code
v r({Q6 )- C,-Ntx-! A Sri ( . LOD d • ba
AL4 p , - v�
Principal occupation/Job title (See Instructions) Employer (See Instructions)
A, N+ 44 A t- LEA(01A1 b-
Date Full name of contributor ❑out-of-state PAC(ID#: Amount of contribution ($)
Contributor address; City; State; Zip Code
Principal occupation/Job title (See Instructions) Employer (See Instructions)
Date Full name of contributor 0 out-of-state PAC(ID#: I Amount of contribution ($)
Contributor address; City; State; Zip Code
Principal occupation/Job title (See Instructions) Employer (See Instructions)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If contributor is out-of-state PAC,please see instruction guide for additional reporting requirements.
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
POLITICAL EXPENDITURES MADE
FROM POLITICAL CONTRIBUTIONS SCHEDULE F1
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Event Expense Loan Repayment/Reimbursement Solicitation/Fundraising Expense
Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment&Related Expense
Consulting Expense Food/Beverage Expense Polling Expense Travel In District
Contributions/Donations Made By Gift/Awards/Memorials Expense Printing Expense Travel Out Of District
Candidate/Officeholder/Political Committee Legal Services Salaries/Wages/Contract Labor Other(enter a category not listed above)
Credit Card Payment
The Instruction Guide explains how to complete this form.
1 Total pages Schedule Ft: 2 FILER NAME 3 Filer ID (Ethics Commission Filers)
3 (0c%a N NA F1-+�-n,� �N o
4 Date 5 Payee name
lit 118 nrtn aro 1.1•EI22N AA-1DE:
6 Amount ($) 7 Payee address; City; State; Zip Code
I$ .9'S I43% G-�S}A` LAIC E C.I rt. E (�EAp�Ar.,c�I 11c glscai-1
8 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE t}�.�� Check if travel outside of Texas.Complete Schedule T.
OF �1 V se_ L�P� . t G I Check if Austin.TX,officeholder living expense
EXPENDITURE
Skov ra. ct,i vvLe�k•T f e c v
e�4ord
t � _ -.
9 Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
Date Payee name
)2.11 115 X40Q1/iN
u-c12NbNOal-
Amount ($) Payee address; City; State; Zip Code
WA-C. 0 141 t u-5t+4-t_ ate_ E Pia1-A,1 of - :1C
Category (See Categories listed at the top of this schedule) Description
PURPOSE I Check if travel outside of Texas.Complete Schedule T.
OFp Check if Austin,TX,officeholder living expense
D
EXPENDITURE Ls) IZEPAty Mem
Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
Date Payee name `� ,p
12c I I a 1n�n.},_.✓ f ay.it i SM c-o r `e vc3L Ak l�FA
Amount ($) Payee address; City; State; Zip Code
2,003a�s 5 MP 1 n stmt 4 Cott.� 1-1-5 1
Category (See Categories listed at the top of this schedule) Description
PURPOSE Check it travel outside of Texas.Complete Schedule T.
OF },S t (]Q�'�se-
Complete
L Check if Austin,TX,officeholder living expense
EXPENDITURE �WX
Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
POLITICAL EXPENDITURES MADE
FROM POLITICAL CONTRIBUTIONS SCHEDULE Fl
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Event Expense InanRepayment/Reimbursement Solicitation/Fundraising Expense
Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment&Related Expense
Consulting Expense Food/Beverage Expense Polling Expense Travel In District
Contributions/Donations Made By Gift/Awards/Memorials Expense Printing Expense Travel Out Of District
Candidate/Officeholder/Political Committee Legal Services Salaries/Wages/Contract Labor Other(enter a category not listed above)
Credit Card Payment
The Instruction Guide explains how to complete this form.
1 Total pages Schedule Fl: 2 FILER NAME 3 Filer ID (Ethics Commission Filers)
3 ptiove-tary M 14E12 x.)ArJo
4 Date 5 Payee name
C1) IIS
Pc.IP,'LArD Ar-e3Err OF CONm Ea
6 Amount ($) 7 Payee address; City; State; Zip Code
a •C?0 �I k - gr0c r SA-y: ?ea-ti \atxAck, 'Q- -; c
8 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE I I Check it travel outside of Texas.Complete Schedule T.
OF t_ve�� p���•
c C� I I Check if Austin.TX,officeholder living expense
EXPENDITURE c.
9 Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
Date Payee name
('DI bile C(-l(3 CS M Acle-r-
Amount ($) Payee address; City; State; Zip Code
5-5 . SD L a(o g r e2:G„J4 Q. o,k ,
Category (See Categories listed at the top of this schedule) Description
PURPOSE Check if travel outside of Texas.Complete Schedule T.
OF R. -� i 7e�(,Le_ I Check if Austin,TX.officeholder living expense
EXPENDITURE IVr
Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
Date Payee name
1 a (131 1 g A,t., (-e ack i v\.-3 Ge Oce v
Amount ($) Payee address; City; State; Zip Code
L{0 . 00 22 t-f b 11431.34.,.;v-,3}0 n St- - pe cc.v kakAd2 -CSC t 9
Category (See Categories listed at the top of this schedule) Description
PURPOSE n Check if travel outside of Texas.Complete Schedule T.
OF 9Ow ��Qp`,e I I Check if Austin,TX,officeholder living expense
EXPENDITURE vJ
W
Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
POLITICAL EXPENDITURES MADE
FROM POLITICAL CONTRIBUTIONS SCHEDULE Fl
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Event Expense Loan Repayment/Reimbursement Solicitation/Fundraising Expense
Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment&Related Expense
Consulting Expense Food/Beverage Expense Polling Expense Travel In District
Contributions/Donations Made By Gift/Awards/Memorials Expense Printing Expense Travel Out Of District
Candidate/Officeholder/Political Committee Legal Services Salaries/Wages/Contract Labor Other(enter a category not listed above)
Credit Card Payment
The Instruction Guide explains how to complete this form.
1 Total pages Schedule Ft: 2 FILER NAME 3 Filer ID (Ethics Commission Filers)
3 Avn r .. M \Ar-A(2.J.) AN DES
4 Date 5 Payee name
CAA 6E5 iM A ft-r
6 Amount ($) 7 Payee address; City; State; Zip Code
S9c •0 2 O to . NcAA, '
8 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE I Check if travel outside of Texas.Complete Schedule T
OF ^ � I I Check if Austin.TX,officeholder living expense
EXPENDITURE t-NA
9 Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
Date Payee name
111 1 146 C e 5 M A%2'v
Amount ($) Payee
address; City; State; Zip Code
(05- O0 lc 0
S . Fe,A, �-�� -06 4s----itaI
Category (See Categories listed at the top of this schedule) Description
PURPOSE Check if travel outside of Texas.Complete Schedule T.
OFr n � ,/)p Check if Austin,TX,officeholder living expense
EXPENDITURE �/VC/'
Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
Date Payee name
I I lc\ C.uEs c,"A le-c
Amount ($) Payee address; City; State; Zip Code
Category (See Categories listed at the top of this schedule) Description
PURPOSE I Check if travel outside of Texas.Complete Schedule T
OF }� � I Check if Austin,TX,officeholder living expense
� a
EXPENDITURE I ' ,1
�'5Q
Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
INTEREST, CREDITS, GAINS, REFUNDS, AND
CONTRIBUTIONS RETURNED TO FILER SCHEDULE K
The Instruction Guide explains how to complete this form. 1 Total pages Schedule K: 2
2 FILER NAME 13 Filer ID (Ethics Commission Filers)
ADRIAN M HERNANDEZ
4 Date 5 Name of person from whom amount is received 8 Amount ($)
-5t✓ kND elz A- Claely I r It ►..) t c»3
11s 6 Address of person from whom amount is received; City; State; Zip Code V e V�
B
I 1 1330 — ,,.• k. kc'A-oY, -rx. 4Aoc-13
7 Purpose for which amount is received I ^ Check if political contribution returned to filer
'fes^ % i♦' c v e-64..\ ‘--
Date Name of person from whom amount is received Amount($)
-3 5c Feot e-u ,\ Cv e 't 4- u, ti i cyrN
l0\t I 's Address of person from whom amount is received; City: State; Zip Code O , 03
t 3 3 o 6e)AA.,1\A:t L�. ,-t, c8
Purpose for which amount is received I I Check if political contribution returned to filer
9 ►V!t clwok c-V L'g Q—
Date Name of person from whom amount is received Amount($)
acc Ee ot Q'ok CV t 7k- \.--\,..1 t
Address of person from whom amount is received; City; State; Zip Code V t D
<< < lk to ‘ U Ge AA,\ vv`\ tu` ...--glro,,�C 4-3oTs'
Purpose for which amount is received_nI Check if political contribution returned to filer
0I \Jt .e C te eGsk.%
Date Name of person from whom amount is received Amount ($)
SSC- IFe-oI.e,...•1,` C e.,04% V vt\oNC\
Address of person from whom amount is received; City; State: Zip Code
03 0 C ; v...k L„_ 4.4,,,,.4rov , -1...-1.0;-130.
a<( ke
Purpose for which amount is received I Check if political contribution returned to filer
Q 1•Qs 1 0L4_oQ c.v e.ts)\ -
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
INTEREST, CREDITS, GAINS, REFUNDS, AND
CONTRIBUTIONS RETURNED TO FILER SCHEDULE K
1
The Instruction Guide explains how to complete this form. Total pages Schedule K: 2
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
ADRIAN M HERNANDEZ
4 Date 5 Name of person from whom amount is received 8 Amount($)
7SG cea -( CV€- i �- lJ�N 1(3r
6 Address of person from whom amount is received: City; State; Zip Code
I1�I 133 o C) �. L-,.. ��� ,, " q-POre
7 Purpose for which amount is received ,/ Check if political contribution returned to filer
0 "I tC�-F� - C►' s
CI-2-0,Q\
Date Name of person from whom amount is received Amount ($)
Address of person from whom amount is received; City; State; Zip Code
Purpose for which amount is received I I Check if political contribution returned to filer
Date Name of person from whom amount is received Amount($)
Address of person from whom amount is received; City; State; Zip Code
Purpose for which amount is received I I Check if political contribution returned to filer
Date Name of person from whom amount is received Amount($)
Address of person from whom amount is received; City; State; Zip Code
Purpose for which amount is received I I Check if political contribution returned to filer
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015