HomeMy WebLinkAbout141212 - Appointment of Campaign Treasurer - CS Citizens For Safe FrackingTexas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989)
APPOINTMENT OF A CAMPAIGN TRE ASURER FORM STA
BY A SPECIFIC-PURPOSE COMMITTEE PG 1
1 Total pages filed:
See STA Instruction Guide for detailed instructions. ;;_
2 COMMITTEE
NAME
3 COMMITTEE
ADDRESS
4 CAMPAIGN
TREASURER
NAME
5 CAMPAIGN
TREASURER
STREET
ADDRESS
(residence or business)
6 MAILING
ADDRESS ¥ same as above
7 CAMPAIGN
TREASURER
PHONE
8 PERSON
APP OINTING
TREASURER
9 SIGNATURE
10 ASSISTANT
CAMPAIGN
TREASURER
(see instructions)
11 ASSISTANT
CAMPAIGN
TREASURER
ADDRESS
12 ASSISTANT
CAMPAIGN
TREASURER
PHONE
www.ethics.state.tx.us
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ADDRESS I PO BOX: APT I SUITE#; CITY; STATE; ZIP CODE
10 o I P e...r .s k ·, Y\ jr Co 11 e. j e., S t<i177 r:gi+o
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NICKNAME
FIRST \ <. °" -\-\·ue, ""' ·, � e..
. . . .
LAST
. . .
S�.a_fer
. . .
STREET ADDRESS (NO PO BOX PLEASE); APT I SUITE#; CITY;
. . ' .
STATE;
Ml
K.
SUFFIX
ZIP CODE
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ADDRESS I PO BOX; APT I SUITE#; CITY; STATE; ZIP CODE
AREA CODE PHONE NUMBER EXTENSION
(t:t79) 515-81\0
FIRST Ml LAST
R \ c..� \Jood,wo.x �
OFFICE USE ONLY
Acct.#
Date ReceiveH AN D �f efa.o
DEC 1 2 2014 f"
DELIVERE[i
HD/PM
Date Processed
Date Imaged
SUFFIX
I understand that I have been appo inted as the campaign tr easurer for this spec ific-purpose
committee and that I am responsible for filing all required reports and that I may be subject
to fines for failure to do so. I am aware of the restrictions in title 15 of the Election Code on
contributions from corporations and labor organizations.
��2L�
FIRST Ml LAST SUFFIX
ADDRESS /PO BOX; APT I SUITE#; CITY; STATE; ZIP CODE
AREA CODE PHONE NUMBER EXTENSION
( )
CONTINUE ON PAGE 2
Revised 09/04/2014
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463 -5800 (TDD 1-800-735-2989)
SPECIFIC-PURPOSE COMMITTEE: FORM STA
PG 2 PURPOSE AND MODIFIED REPORTING DECLARATION
13 COMMITTEE NAME
14 COMMITTEE
PURPOSE
D SUPPORT CANDIDATE
CANDIDATE I OFFICEHOLDER NAME
D OPPOSE CANDIDATE OFFICE SOUGHT (candidate) /OFFICE HELD (officeholder)
D ASSIST OFFICEHOLDER
�SUPPORT MEASURE
D oPPOSE MEASURE
15 MODIFIED
REPORTING
DECLARATION
www.ethics.state.tx.us
BALLOT IDENTIFICATION OF ME ASURE I # ELECTION DATE
Month / Day / Year
� f Cd>\\ e.3 e.. �'S+<-'-+t.:>v-. 1)-12.s� d«-lf\i"'S.
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 cycle includes a primary election, a general election, and an y 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.
_2_Q__L�L :-_2�_L5 __ _
Year of election(s) or election cycle to
which decl aration applies
Signature of Campaig n Treasurer
ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED
Revised 09/04/2014