HomeMy WebLinkAboutOWENS, WOODY_DECEMBER 4 2020_CAMPAIGN FINANCE REPORTCANDIDATE/Os
FICE
0
DER
FORM
C/OH
CAMPAIGN
FINANC
R. PORT
COVER
SHEET
PG
1
The
C/OH
Instruction
Guide
explains
how to
complete
this
form.
1 Filer ID (Ethics Commission Filers)
2 Total pages filed:
I/
3 CANDIDATE/
OFFICEHOLDER
NAME
MS /
MRS
M~ FIRST
MI
,41
OFFICE
USE
ONLY
P & ) AirUO
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Date Received
NICKNAME LAST SUFFIX
'
1020
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1
CANDIDATE
OFFICEHOLDER
MAILING
ADDRESS
/
ADDRESS / PO BAPT / SUITE It; CITY; STATE; ZIP CODE
I
Change
of
Address
1 /'7 /.
5 CANDIDATE/
AREA CODE PHONE NUMBER EXTENSION
OFFICEHOLDER
! ')
-
(Date Hand
PHONE
( 1 `.
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- Date Postmarked
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6 CAMPAIGN
ms / MRS /
R FIRST MI
Receipt It
Amount
$
TREASURER
`/A2 ' `r�,,�1V -/6' 6I
NAME
�'
NICKNAME LAS T\
,
SUFFIX
Date Processed
4-2
Date Imaged
. / �, « , ,--->
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7 CAMPAIGN
STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; ZIP CODE
TREASURER
ADDRESS
(Residence
or
Business)
2117 (zpuchiy
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PHONE
o
1 "77-fr
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Q52
9 REPORT
TYPE
I
I January 15 1
I
30th day before election WRunoff
[ I
15th day after campaign
treasurer appointment
(Officeholder Only)
I
July 15
8th day before election
I I
Exceeded $500 limit # [ I
Final Report (Attach C/OH - FR)
10
PERIOD
COVERED
Month Day
t.),5 / 1.1
Year Month Day Year
)
(.3 an 1„. N
THROUGH /1-1;29e9
I
3
11
ELECTION
ELECTION DATE
ELECTION TYPE
Month Day Year
Primary
Runoff
( I
Other
Description
/2 '
General
( I
Special
b
______
12 OFFICE
OFFICE HELD (if any)
I c.
) sgbi de
13
OFFICE
SOUGHT (if known)
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GO TO
PAGE
2
Forms
provided
by Texas
Ethics
Commission www.ethics.state.tx.us
Revised
9/8/2015
•
CANDIDA
E / OFFICEHOLD
R
FORM
C/OH
CAMPAIGN
FINANCE
REPORT
COVER
SHEET PG 2
14
C/OH
NAME
%/1
%t
15 Filer ID (Ethics Commission Filers)
ite40Plint)
17
11-Priki
-("& t
16
NOTICE
FROM
THIS BOX IS FOR NOTICE OF POLITICAL CONTRIBUTIONS ACCEPTED OR POLITICAL EXPENDITURES MADE BY POLITICAL COMMITTEES TO
SUPPORT THE CANDIDATE / OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATES OR OFFICEHOLDER'S
KNOWLEDGE OR CONSENT. CANDIDATES AND OFFICEHOLDERS ARE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY RECEIVE NOTICE
OF SUCH EXPENDITURES.
POLITICAL
COMMITTEE(S)
COMMITTEE TYPE
COMMITTEE NAME
I
IGENERAL
COMMITTEE ADDRESS
SPECIFIC
COMMITTEE CAMPAIGN TREASURER NAME
1
1 Additional
Pages
COMMITTEE CAMPAIGN TREASURER ADDRESS
1.
TOTAL POLITICAL
PLEDGES, LOANS,
CONTRIBUTIONS OF $50 OR LESS (OTHER THAN
OR GUARANTEES OF LOANS), UNLESS ITEMIZED
17
TOTALS
CONTRIBUTION
EXPENDITURE
TOTALS
2. TOTAL
(OTHER
POLITICAL
THAN
PLEDGES,
CONTRIBUTIONS
LOANS,
OR
GUARANTEES OF LOANS)
1
01)
$n,�
se
3. TOTAL POLITICAL EXPENDITURES OF $100 OR LESS,
UNLESS ITEMIZED
$ r
4.
TOTAL
POLITICAL
EXPENDITURES
$j:
/ 9/9 T
�s
V'
5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY
OF REPORTING PERIOD
'
CONTRIBUTION
BALANCE
if.
3 e_.:,
6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
LAST DAY OF THE REPORTING PERIOD
OUTSTANDING
LOAN
TOTALS
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
t'
2
p�A
P NotatRENEE KRQSS
`y
under
Titl
15,
Election
C
e.
f
ID #132042519
My Commission Expires
1
of 11' June 6, 2023
�-----4
♦
Si
AFFIX NOTARY STAMP / SEALABOVE
Mature of
Candidate or Officeholder
Alf\
Sworn to and subscribed
before
me,
by
the
said WODC\nD x��,��S
, this
the
I
day
of
vsycembe,r
1 20 9-t) , to certify which,
witness my
hand
and seal
of office.
.y
Ip
r J� �j
0-
KITS
(2 pioSec
Signature Printed
of officer administering oath name of officer 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
C/OH
PG
3
FORM
SHEET
COVER
19
FILER NAME
"all&
0
20 Filer ID (Ethics Commission
Filers)
ern, evi /2
-
21
SCHEDULE SUBTOTALS
NAME OF SCHEDULE
SUBTOTAL
AMOUNT
1.
SCHEDULE AI: MONETARY POLITICAL CONTRIBUTIONS
SiU•,(JVs
i.
�
2.
SCHEDULE A2: NON -MONETARY (IN -KIND)
POLITICAL CONTRIBUTIONS
f
$
I
I
3•
SCHEDULE B: PLEDGED CONTRIBUTIONS
$
I
I
4.
SCHEDULE E: LOANS
$
I
I
5•
SCHEDULE Fl: POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS
¶1927Iau
I /fi
6.
SCHEDULE F2: UNPAID INCURRED OBLIGATIONS
$
I I
7'
SCHEDULE F3: PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS
$
I I
8.
SCHEDULE F4: EXPENDITURES MADE BY CREDIT CARD
$
I
I
9.
SCHEDULE G: POLITICAL EXPENDITURES MADE FROM PERSONAL FUNDS
$
I
I
10.
SCHEDULE H: PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH
$
I I
11.
SCHEDULE I: NON-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS
$
I
J
12.
I
SCHEDULE K: INTEREST,
RETURNED TO FILER
CREDITS, GAINS, REFUNDS, AND CONTRIBUTIONS
$
I
orms provided by I exas bthics Commission
www.ethics.state.tx.us
Revised 9/8/2015
POLITICAL
FROM POLITICAL
MADE
CONTRIBUTIONS SCHEDULE Fl
EXPENDITURES
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Event Expense Loan Repayment/Reimbursement Solicitatlon/FundralsingExpense
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 SalariesNVages/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:
3
2 FILER
i
NAME
eicar-t)ii)
ti) i
Lei.ei
91
�
3 Filer ID (Ethics Commission Filers)
/ A
isrr
/� y� /��
4 Date iii
5 Payee name
JoiL, e ...3"
_
6 Amount ($)
7 Payee address; City; State; Zip Code
77 13y
edRIAscrdicerve_ Litz -1,-4 .-
x 75:
8
PURPOSE
(a) Category (See Categories listed at the lop of Is schedule)
(b)
Description
of Texas. Complete Schedule T.
I
I Check if travel outside
OF
I Check if Austin,
TX, officeholder living expense
EXPENDITURE
3771
.
/Wit . °
P
9 Complete
ONLY
if direct
Candidate / Officeholder name Office sought Office held
expenditure
to benefit C/OH
Date
/
/!
Payee
name
2
.
it, A
Amount ($)
Payee address; ity; State; Zip Co
ir x"7
gy7r,fytfll
/6r ?4 ,�?
`�
A � %
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
�
I
Check if travel outside of Texas. Complete Scheduler.
OF
I ((
I
Check if Austin, TX, officeholder living expense
EXPENDITURE
/
el4/5 C-410/11-5 -
(-)
Complete
ONLY
if direct
Candidate / Officeholder
name Office sought Office held
expenditure
to benefit C/OH
Date
Payee name
ii„
2; ,., #2L2 it U
Lel u7C5
Amount ($)
Payee address; City; State; Zip Code
/I? LP / 9
teazyp
i 4 I
e e/A22--;•P /Ai 7 7:5S 1
/- ire,
Category (See Categories listed at the top of this s hedule)
Description
PURPOSE
I
Check if travel outside
of Texas. Complete Schedule T•
OF
EXPENDITURE
I
I Check if Austin,
TX, officeholder living expense
�a'�!� -- x/o
tt' �✓ -
Complete
ONLY
if direct
Candidate / Officeholder name Office sought Office held
expenditure
to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission
www.ethics.state.tx.us
Revised 9/8/2015
POLITICAL
EXPENDITURES
CONTRIBUTIONS
MADE
SCHEDULE
Fl
i
POLITICAL
FROM
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Event Expense Loan Repayment/Reimbursement Solicitation/FundraisingExpense
Accounting/E3anking
Fees Office Overhead/Rental Expense Transportation Equipment & Related Expense
Consulting Expense Food/Beverage Expense Polling Expense Travel In District
Contributions/Donations Made By
Gift/Awards/Memorials Expense Printing Expense Travel Out Of District
Candidate/Officeholder/Political
Committee Legal Services
Credit Card Payment
Salaries/Wages/Contract
Labor Other (enter a category not listed above)
The Instruction Guide explains how to complete this form.
1 Total pages Schedule Fl:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
--A
LiCa? p 4 ff
#
,,
4 Date
5 Payee name
f' A 7 r �za
(
4 0lQ.� e
6 Amount ($)
7 Payee address; City; State;
Zip Code
417/ c. / 5j
790 /5.x-9 m
z
..
' jv J /�' 7X� 6 /`f
i
8
(a) Category (See Categories listed at the top this schedule)
(b)
Description
PURPOSE
I Check if travel outside
of Texas. Complete Schedule T.
OF
EXPENDITURE
Check if Austin,
TX, officeholder living expense
f J
/CZ
(17
Zer#19ell
9 Complete
ONLY if direct
Candidate / Officeholder name Office sought Office held
expenditure to benefit C/OH
Date
Payee name
4
,
A7 e el -5 —
2
Amount ($)
Payee addr ; City; State; Zip Code
41-1/7
3'4/ et-2A-i-
..., . sn
,epd an d.,,467 op v ,,,,
'9n/0i-95 ii,e,
,. .
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
Check if travel outside of Texas. Complete Schedule T.
II
OF
EXPENDITURE
Check if Austin, TX, officeholder living expense
(1z'z-P
Complete
p
ONLY
if direct
Candi t��old�r name Office sought Office held
expenditure to benefit C/OH
Date
Payee name
1/1 •frv;? „1 grk:V 2).-'
egg/idea.1 /
Amount ($)
Payee address; ity; State; Zip Code
1/42c.
2421
75A
l
411 -1-a
.
A.
Category (See Gat ories listed at the to of this schedule)
Y p
Description
-2
PURPOSE
Check if travel outside of Texas. Complete Schedule T.
OF
EXPENDITURE
ri
r•
AC/
Ir 1
Check if Austin, TX, officeholder living expense
a',772 . lag
Complete
p
ONLY
if direct Candida
e /
n me
Office sought Office held
Off
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
I
POLITICAL EXPENDITURES
FROM POLITICAL
CONTRIBUTIONS
MADE
SCHEDULE Fl
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Event Expense Loan Repayment/Reimbursement Solicitation/Fundralsing Expense
Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment & Related Expense
Consulting Expense Food/Severage Expense Polling Expense Travel In District
Contnbutions/Donatlons 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 fisted above)
Credit Card Payment
The instruction Guide explains how to complete this form.
1 Total pages
Schedule
Fl:
NAly\E
ail/ - re/ V
'
f
`a-^
ttlii)51 42
3 Filer ID (Ethics Commission Filers)
2 FILE
4 Date
ze2 eal-3.--
) a-
5 Payee name 5 ) c
/9,71,17/440fr ,,v
4
itte,j(i
6 Amount ($)
7 Payee address; City; State; Zip Code
r
t -re a
A Cis y/yw i
8iyfeyy,
if ye c i
8
(a) Category (See Categories listed at the top of this schedule)
(b)
Description
PURPOSE
I
I Check if travel outside
of Texas. Complete Schedule T.
OF
EXPENDITURE
r c (
t
[ I Check if Austin,
TX, officeholder living expense
9 Complete
ONLY
if direct
Candidate
/ Officehol
er ame Office sought Office held
expenditure
to benefit
C/OH
Date
Payee name
/ -# • 2i)2 L,
49/%97)
r it") T,
Amount
($)
Payee addres7 City; State; Zip
A/7 - 'hi 0
Code
111MA -RC 1
/7( ‘,?Ths
PURPOSE
Category (See Categories liste'c1 at the top of this schedule)
I
Description
Check if travel outside of Texas. Complete Schedule T.
OF
EXPENDITURE
I I
Check if Austin, TX, officeholder living expense
/-"---->e41 / .it,e&
,5
- R,
Complete
ONLY
if direct
Candidate / Officeholder name Office sought Office held
expenditure
to benefit
C/OH
Date
Payee name
//'- / --'y� fl1 1)
Aid 7 /�7�
d
-474
Amount ($)
Payee address; City; State; Zip Code
9/, 46c)
- e'
?
/ I/ ) _el /---9 /V) CI i O
0)--fil/Mir
1.----,14% 7 7d Sy
Category (See Categories listed at the top oft
is schedule)
Description
PURPOSE
of Texas. Complete Schedule T.
I
I Check if travel outside
OF
EXPENDITURE
67e1
.
`
I
I Check if Austin,
TX, officeholder living expense
Complete
ONLY if direct
Candidate / Officeholdername Office sought Office held
expenditure
to benefit
C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission
www.ethics.state.tx.us
Revised 9/8/2015
MONETARY
POLI
ICAL
CONTRIBUTIONS
SCHEDULE
Al
I
The
Instruction Guide
explains
how to complete
this
form.
1
Total pages Schedule
Al:
e ,
'I
2 FILER NAME
air
-7)9/12 z A,,,,,,,,,
3 Filer ID (Ethics Commission Filers)
4 Date
jfea/Z)4'td&
5 Full name of contributor
eAh4eijSmn
6 Contributor address;
?b1,40 45-.- kit riii
out-of-state
City;
PAC (ID#:
State;
)
7 Amount of contribution
Ofe0
7
($)
❑
IA
Zip Code
/°
•
77
a)
8 Principal
deno
occupation
/ Job
7/z
title (See
Instruct
`•
on )
9
(See Instructions)
Employer
I
Date
//Y/2tW
/
Full
Contributor
name
of
contributor
PAC
City; State;
°D#:
)
Amount of contribution
/Ansia'
($)
❑
out-of-state
Zip Code�
7W/
)1?
address;
Princip
al occupation / Job title (See Instructions)
tilinninatir r 447,Y7 de al
Employer (See
Instructions)
Date
• f
Full name of contributor
/ie//u9in g0,5W
Contributor address;
/ inei>s
City;
State;
1
PAC
.
(ID#:
)
Amount of contribution
ili
e4)
($)
❑
out-of-state
,g
Zip Code
S
749,;
Principal
occupation / Job
7Atirt as
title (See
I
a
tructions)
i
d -
Employer (See Instructions)
4/4
Date
41/9244e)
Full name
,frdewrnr
ffl/Jj,tJ
of
address;
contributor
*
rineth,
t e, IA Qj
out-of-state
PAC (ID#:
City; State;
y
r 147b
)
Amount of contribution
,Contributor
< 3
t
($)
❑
Zip Code
Principal
p
AZ?
occupation / Job title(See
p
•r4)
Ins ructions
)
eekel
le
Employer (See Instructions)
i
If
contributor
ATTACH
is
ADDITIONAL
PAC,
please
COPIES
see
instruction
OF
THIS SCHEDULE
guide
for
additional
AS
NEEDED
reporting
requirements.
out-of-state
Forms provided by Texas Ethics Commission
www.ethics.state.tx.us
Revised 9/8/2015
MONETARY POLITICAL CONTRIBUTIONS
SCHEDULE Al
The Instruction Guide explains how to complete this form.
1 Total pages Schedule Al:
5
2 FILER NAME
S2 LeItelY
4 Date
§4-20,P
5 Full name of contributor
out-of-state PAC (1D#: )
z20fic,--- Ava ny.d. Pmo
•6 Con ri utor address; e City; State; Zip Code
4frebta Ana s&r//9J T zfzijz.
8 Principal occupation / Job title (See Instructions)
4%
47,sigvAietivel
3 Filer ID (Ethics Commission Filers)
7 Amount of contribution ($)
9 Employer (See Instructions)
evits
Date
/A -A.)485;
Full name of contributor
out-of-state PAC (ID#: )
/4,~. 2,1e 2
Contributor address;
City; State; Zip Code
1/7e 77'y
Principal occupation / Job title (See Instructions)
9,ii�P.� :.1rt9 iLti paG
Date
,t
Full name of contributor
erne): salloc
Contributor address;
aTtertor
Principal occupation / Job title (See Instructions)
Ale;i714 gitiOrgd 1-> 1
Date
kinds,
Full name of contributor
7; 77,77
Employer (See Instructions)
out-of-state PAC (ID#: )
City; State; Zip Code
77 eve
Employer (See Instructions)
Amount of contribution ($)
a 'a
Amount of contribution ($)
out-of-state PAC (ID#: )
16)444s
Contributor address;
/grim //sew*
Principal occupation / Job title (See Instructins)
f a f
City; State; Zip Code
dwren'
n S49
Employer (See Instructions)
Amount of contribution ($)
P
l
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If contributor is out-of-state PAC, please see instruction guide for additional reporting requirements.
Forms provided by Texas Ethics Commission www.ethics.state.tx.us
Revised 9/8/2015
MONETARY
POLITICAL
CONTRIBUTIONS
SCHEDULE
Al
The
Instruction Guide
explains
how to complete
this
form.
1 Total
pages Schedule
Al:
d
2 FILER
s
NA E
06FIV
i it)
•
14-2tAdO
3 Filer ID (Ethics Commission
Filers)
.lc
4 Date
7i)
///2
5 Full name of contributor
•//Jt�7.
6 Contributor address;
6/Jz6n,2yte4
/ fi- f.P
out-of-state PAC
•
City; State;
(ID#:
)
7 Amount
- ,a
of contribution ($)
7
❑
•
/mn4
_
Code
`
Zip
47212
8 Principl
occupation / Job title (Sestructi
AilWrie
s)
ormitisi
•la--
9 Employer (See Instructions)
Date
''2.y
•
Full
name of contributor
4,41 •
a
Et
dress;
ftr//
out-of-state
.11-2'
City; Y,
PAC (1D#:
State;
)
Amount of contribution
‘c.t° dee
($)
Q
Zip Code
Contributor
Principal
occupation
41/14M/A
/ Job title (See
g
Instructions)
ti
Employer (See Instructions)
?
Date
//1-g; "t9 P,
Full name of contributor
.
rn z 1 i eri
Contributor address;
I * a la t M Pk
t
Pe/CZ/1
out-of-state PAC (ID#:
City; State;
9 7 1 is Zei
)
Amount of contribution ($)
.--
J �v.
❑
Zip Code
77157/
Principal occupation / Job title (See
_t7,,/,‘siyh,Arie
Instructions)
a/Ae.
(See Instructions)
Employer
3
Date
49197FAa
Full name of contributor
/9/terpveIx e,01 4
Contributor address;
VarAerin
out-of-state PAC
City; ; State;
e,
km
(ID#:
Zip
)
Amount of contribution
'..:
• ,>
($)
❑
Code,
a 7.79-75et
/
Principal occupation
tee „t) PIS
/ Job title (See
Er /3"Asize,2
Instructio
Employer (See Instructions)
.
If
contributor
ADDITIONAL
PAC,
please
COPIES
see
OF
instruction
THIS
guide
SCHEDULE
for
additional
AS
NEEDED
reporting
requirements.
ATTACH
is out-of-state
Forms
provided
by Texas
Ethics
Commission
IA/IA[1A! n+i,;an,....tea-.
l.. . ._
. va. ..vv.ululG..
Revised 9/8/2015
MONETARY
POLITICAL
CONTRIBUTIONS
Al
SCHEDULE
The
instruction Guide
explains
how to complete
this form.
1 Total pages Schedule Al:
)
2
FILER N M
('
SdieW
.
ca
t
3 Filer ID (Ethics Commission Filers)
4 Date
/Fs 4,. 21)0610
5
' d
6
/ 5
Full
contributor
/ .
fretn-
ss
JeA52up'.1a,Ea,'$
PAC (ID#:
State;
)
7 Amount of contribution ($)
7 r, ,
name of
46i7esfiWele'
Contributor addre
Veil) AA
❑
out-of-state
City;
Zip Code
Principal
,!
415
occupation / Job title (See Instructions)
t
i�fielWJ /2P,7P/Or
g Employer(See Instructions)
Date
iii,-/ftrzow•
e4frizies
•
Full name of contributor
erfred
out-of-state PAC (ID#:
City; State;
fr,re/VA/611Y
)
Amount of contribution ($)
4 4,aa?
❑
Zip Code
Zee
• • • - ------
Contributor address;
6 ht" 7516
' 1
occupation / Job title (See Instructions
vy
Employer (See Instructions)
Date
elligf2411
Full
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THIS
guide
SCHEDULE
for
additional
AS NEEDED
reporting
requirements.
ATTACH
is out-of-state
Forms
provided
by Texas
Ethics
Commission www.ethics.state.tx.us
Revised
9/f3/2015
MON
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POLl
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CONTRIBUTIONS
SCHEDULE
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Amount of contribution ($)
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Date
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Amount of contribution ($)
❑
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Principal occupation
/ Job title (See Instructions)
Employer
(See Instructions)
Date
Full name of contributor
Contributor address;
out-of-state PAC (ID#:
City; State; Zip
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Amount of contribution ($)
❑
Code
Principal occupation / Job title (See Instructions)
Employer
(See Instructions)
If
contributor
ADDITIONAL
PAC,
please
COPIES
see
OF
instruction
THIS
guide
SCHEDULE
for
additional
AS
NEEDED
reporting
re
requirements.
uiremen s.
ATTACH
is out-of-state
Forms
provided
by
Texas
Ethics
Commission www.ethics.state.tx.us
Revised
9/8/2015