Appointment Of A Campaign Treasurer By A Specific-Purpose Committee {STA}

Revised //201 Forms provided by Texas Ethics Commission www.ethics.state.tx.us APPOINTMENT OF A CAMPAIGN TREASURERBY A SPECIFIC-PURPOSE COMMITTEEFORM STAPG 1 AREA CODEPHONE NUMBEREXTENSION () MS / MRS / MRFIRSTMI000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000NICKNAMELASTSUFFIX FIRSTMILASTSUFFIXI understand that I have been appointed as the campaign treasurer for this specific-purposecommittee and that I am responsible for filing all required reports and that I may be subject tofines for failure to do so. I am aware of the restrictions in title 15 of the Election Code on contributionsfrom corporations and labor organizations. ADDRESS / PO BOX;APT / SUITE #;CITY;STATE;ZIP CODEFIRSTMILASTSUFFIX AREA CODEPHONE NUMBEREXTENSION() Total pages filed:ADDRESS / PO BOX;APT / SUITE #;CITY;STATE;ZIP CODESTREET ADDRESS (NO PO BOX PLEASE);APT / SUITE #;CITY;STATE;ZIP CODECOMMITTEENAMECOMMITTEEADDRESSCAMPAIGNTREASURERNAMECAMPAIGNTREASURERSTREETADDRESS(residence or business)MAILINGADDRESS same as aboveCAMPAIGNTREASURERPHONEPERSONAPPOINTINGTREASURERSIGNATUREASSISTANTCAMPAIGNTREASURER(see instructions)ASSISTANTCAMPAIGNTREASURERADDRESSASSISTANTCAMPAIGNTREASURERPHONEADDRESS / PO BOX;APT / SUITE #;CITY;STATE;ZIP CODE123456789101112 CONTINUE ON PAGE 2Signature of Campaign TreasurerFiler ID #OFFICE USE ONLYDate Received Receipt #Date Hand-delivered or PostmarkedDate ProcessedAmount $ Date ImagedSee STA Instruction Guide for detailed instructions.If you are involved in a School District Bond Election, you must file Form STA with the local filing authorityBEFORE sending a file-stamped copy to the Texas Ethics Commission. American LegalNet, Inc. www.FormsWorkFlow.com Revised //201 Forms provided by Texas Ethics Commission www.ethics.state.tx.usCOMMITTEEPURPOSE DESCRIPTIONELECTION DATEMonthDayYear CANDIDATE / OFFICEHOLDER NAMEOFFICE SOUGHT (candidate) / OFFICE HELD (officeholder)BALLOT IDENTIFICATION OF MEASURE / # COMPLETE THIS SECTION ONLY IF YOU ARE CHOOSINGMODIFIED REPORTING. SUPPORT CANDIDATE ASSIST OFFICEHOLDER OPPOSE CANDIDATE 225225This declaration must be filed no later than the 30th daybefore the first election to which the declaration applies. 225225225225The modified reporting declaration is valid for one election cycle only. 225225(An election cycle includes a primary election, a general election, and any related runoffs.)The committee does not intend to accept more than $500 in politicalcontributions or make more than $500 in political expenditures (excludingfiling 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-electionreports and, if necessary, a runoff report.Year of election(s) or election cycle towhich declaration appliesSignature of Campaign Treasurer SPECIFIC-PURPOSE COMMITTEE:PURPOSE AND MODIFIED REPORTING DECLARATIONFORM STAPG 2COMMITTEE NAMEMODIFIEDREPORTINGDECLARATIONATTACH ADDITIONAL COPIES OF THIS FORM AS NEEDED131415 SUPPORT MEASURE OPPOSE MEASURE TEC Filers may send this form to the TEC electronically at treasappoint@ethics.state.tx.us or mail toTexas 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:This appointment is effective on the date it is filed with the appropriate filing authority. American LegalNet, Inc. www.FormsWorkFlow.com