Revised 12/7/2017 Forms provided by Texas Ethics Commission www.ethics.state.tx.us FORM ACTAPG 1 000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 ()NEWNEW NEWNEW NEW GO TO PAGE 2 3 21CANDIDATENAMETotal pages filed:CANDIDATENAMECANDIDATEMAILINGADDRESSOFFICE HELD(if any)OFFICESOUGHT(if known)CAMPAIGNTREASURERNAMECAMPAIGNTREASURERSTREETADDRESSCAMPAIGNTREASURERPHONECANDIDATESIGNATUREAREA CODEPHONE NUMBEREXTENSIONMS / MRS / MRFIRSTMINICKNAMELASTSUFFIXMS / MRS / MRFIRSTMINICKNAMELASTSUFFIXADDRESS / PO BOX;APT / SUITE #;CITY;STATE;ZIP CODESTREET ADDRESS (NO PO BOX PLEASE);APT / SUITE #;CITY;STATE;ZIP CODE579101112 8 4See ACTA Instruction Guide for detailed instructions.Use this form for changes to existing information only. Do not provide information previously disclosed.AMENDMENT: APPOINTMENT OF ACAMPAIGN TREASURER BY A CANDIDATENEWNEW ()NEWCANDIDATEPHONEAREA CODEPHONE NUMBEREXTENSION6 OFFICE USE ONLY Date Received Signature of CandidateI am aware of my responsibility to file timely reports as required by title 15 ofthe Election Code.I am aware of the restrictions in title 15 of the Election Code on contributionsfrom corporations and labor organizations.I am aware of the Nepotism Law, Chapter 573 of the Texas Government Code.Date Signed (residence or business) FILER ID # Receipt #Date Hand-delivered or PostmarkedDate ProcessedAmount $ Date Imaged American LegalNet, Inc. www.FormsWorkFlow.com Revised 12/7/2017 Forms provided by Texas Ethics Commission www.ethics.state.tx.usFORM ACTAPG 2AMENDMENT:CANDIDATE MODIFIED REPORTING DECLARATIONCANDIDATENAME NEW14 MODIFIEDREPORTINGDECLARATIONI do not intend to accept more than $500 in political contributionsor make more than $500 in political expenditures (excluding filingfees) in connection with any future election within the election cycle.I understand that if either one of those limits is exceeded, I will berequired to file pre-election reports and, if necessary, a runoffreport. Year of election(s) or election cycle towhich declaration applies Signature of Candidate13225225This declaration must be filed no later than the 30th day beforethe first election to which the declaration applies. 225225COMPLETE THIS SECTION ONLY IF YOU ARECHOOSING MODIFIED REPORTING225225The modified reporting option is valid for one election cycle only. 225225(An election cycle includes a primary election, a general election, and any related runoffs.)225225Candidates for the office of state chair of a political partymay NOT choose modified reporting. 225225This appointment is effective on the date it is filed with the appropriate filing authority. TEC Filers may send this form to the TEC electronically at email@example.com or Fax this form to (512) 463- or mail to Texas Ethics CommissionP.O. Box 12070Austin, TX 78711-2070 Non-TEC Filers must file this form with the local filing authorityDO NOT SEND TO TECFor more information about where to file go to:https://www.ethics.state.tx.us/whatsnew/NewFilersGettingStarted.html American LegalNet, Inc. www.FormsWorkFlow.com
Success: Your message was sent.