Specific-Purpose Committee Special Session Report {SPAC-SS}

Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) SPECIFIC-PURPOSE COMMITTEE SPECIAL SESSION REPORT 1 ACCOUNT # (Ethics Commission filers) FORM SPAC-SS COVER SHEET PG 1 2 Total pages filed: 3 COMMITTEE NAME OFFICE USE ONLY Date Received 4 COMMITTEE ADDRESS ADDRESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP CODE change of address Date Hand-delivered or Postmarked Receipt # Amount 5 CAMPAIGN TREASURER NAME MS / MRS / MR FIRST MI Date Processed NICKNAME LAST SUFFIX 6 CAMPAIGN TREASURER'S STREET ADDRESS (residence or business) STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; 7 CAMPAIGN TREASURER'S MAILING ADDRESS change of address STREET OR PO BOX; APT / SUITE #; CITY; STATE; 8 CAMPAIGN TREASURER PHONE AREA CODE PHONE NUMBER EXTENSION ( ) Month Day Year Month Day Year 9 PERIOD COVERED THROUGH GO TO PAGE 2 www.ethics.state.tx.us Date Imaged ZIP CODE ZIP CODE Revised 09/01/2007 American LegalNet, Inc. www.FormsWorkFlow.com Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) SPECIFIC-PURPOSE COMMITTEE SPECIAL SESSION REPORT 10 COMMITTEE NAME FORM SPAC-SS COVER SHEET PG 2 ACCOUNT # (Ethics Commission filers) 11 COMMITTEE PURPOSE CANDIDATE (Attach lists on plain paper to complete this report if necessary.) CANDIDATE / OFFICEHOLDER NAME OFFICEHOLDER OFFICE SOUGHT (candidate) / OFFICE HELD (officeholder) SUPPORT (Candidate or Measure) OPPOSE (Candidate or Measure) MEASURE BALLOT IDENTIFICATION / # ELECTION DATE Month Day Year DESCRIPTION ASSIST (Officeholder) 12 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 under Title 15, Election Code. Signature of campaign treasurer AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said ______________________________________, this the ___________ day of _____________, 20 _______ , to certify which, witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath www.ethics.state.tx.us Revised 09/01/2007 American LegalNet, Inc. www.FormsWorkFlow.com Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) POLITICAL CONTRIBUTIONS OTHER THAN PLEDGES OR LOANS The Instruction Guide explains how to complete this form. 2 FILER NAME 1 3 SCHEDULE A Total pages Schedule A: ACCOUNT # (Ethics Commission filers) 4 Date 5 Full name of contributor out-of-state PAC (ID#:_________________________) 7 Amount of contribution ($) 8 In-kind contribution description (if applicable) 6 Contributor address; City; State; Zip Code 9 Principal occupation / Job title (See Instructions) 10 Employer (See Instructions) Amount of contribution ($) Date Full name of contributor out-of-state PAC (ID#:_________________________) Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) (If travel outside of Texas, complete Schedule T) Employer (See Instructions) Date Full name of contributor out-of-state PAC (ID#:_________________________) Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Date Full name of contributor Employer (See Instructions) out-of-state PAC (ID#:_________________________) Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Date Full name of contributor Employer (See Instructions) out-of-state PAC (ID#:_________________________) Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED If contributor is out-of-state PAC, please see instruction guide for additional reporting requirements. www.ethics.state.tx.us (If travel outside of Texas, complete Schedule T) In-kind contribution description (if applicable) Amount of contribution ($) In-kind contribution description (if applicable) (If travel outside of Texas, complete Schedule T) Amount of contribution ($) In-kind contribution description (if applicable) (If travel outside of Texas, complete Schedule T) Amount of contribution ($) In-kind contribution description (if applicable) (If travel outside of Texas, complete Schedule T) Revised 09/01/2007 American LegalNet, Inc. www.FormsWorkFlow.com Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) PLEDGED CONTRIBUTIONS SCHEDULE B-SS (FOR FORMS C/OH-SS AND SPAC-SS) 1 The Instruction Guide explains how to complete this form. 2 FILER NAME 3 Total pages Schedule B-SS: ACCOUNT # (Ethics Commission filers) 4 Date 5 Full name of pledgor out-of-state PAC (ID#:__________________________) 7 Amount of pledge ($) 8 In-kind description (if applicable) 6 Pledgor address; City; State; Zip Code 9 Principal occupation / Job title (See Instructions) 10 Employer (See Instructions) Date Full name of pledgor out-of-state PAC (ID#:__________________________) Pledgor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) Date Full name of pledgor out-of-state PAC (ID#:__________________________) Pledgor address; City; State; Zip Code Principal occupation / Job title (See Instructions) (If travel outside of Texas, complete Schedule T) Employer (See Instructions) Date Full name of pledgor out-of-state PAC (ID#:__________________________) Pledgor address; City; State; Zip Code Principal occupation / Job title (See Instructions) (If travel outside of Texas, complete Schedule T) Employer (See Instructions) Date Full name of pledgor out-of-state PAC (ID#:__________________________) Pledgor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) ATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED If contributor is out-of-state PAC, please see instruction guide for additional reporting requirements. www.ethics.state.tx.us (If travel outside of Texas, complete Schedule T) Amount of pledge ($) In-kind description (if applicable) (If travel outside of Texas, complete Schedule T) Amount of pledge ($) In-kind description (if applicable) Amount of pledge ($) In-kind description (if applicable) Amount of pledge ($) In-kind description (if applicable) (If travel outside of Texas, complete Schedule T) Revised 09/01/2007 American LegalNet, Inc. www