Confidential Social Security Information

Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) CONFIDENTIAL SOCIAL SECURITY INFORMATION FORM SSN A lobby registrant must submit this form to the Texas Ethics Commission in compliance with Tex. Fam. Code Sec. 231.302(c)(1), not as a means to register as a lobbyist. To register with the Texas Ethics Commission as a lobbyist, you must file the LOBBY REGISTRATION (FORM REG) with a filing fee. 1 REGISTRANT NAME LICENSE / ACCOUNT # PAGE # 2 REGISTRANT'S HOME ADDRESS (Address / PO Box, Apt/ Suite #) OFFICE USE ONLY (City, State, Zip Code) 3 SOCIAL SECURITY NUMBER NOTE: The Social Security Number WILL NOT be disclosed in any public file or on any public document maintained by the Texas Ethics Commission. ___________ - _________ - __________ 4 DATE OF BIRTH Month Day Year / 5 EMPLOYER NAME / HD / PM Receipt # Amount 6 EMPLOYER'S ADDRESS Legal (Address / PO Box, Apt/ Suite #) Date Processed (City, State, Zip Code) Date Imaged 7 SIGNATURE To the best of my knowledge the accompanying document is true and correct and includes all information to be reported by me under Chapter 231, Subchapter D, Family Code. _____________________________________________________________ Signature of Registrant www.ethics.state.tx.us Revised 11/30/2004 American LegalNet, Inc. www.FormsWorkFlow.com