Smith Semi July 2021DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
CANDIDATE / OFFICEHOLDER
FORM C/OH
CAMPAIGN
FINANCE REPORT
COVER SHEET PG 1
1 Filer ID (Ethics Commission Filers)
2 Total pages filed:
The C/01-1 Instruction Guide explains how to complete this form.
3 CANDIDATE/
ME I MRS / MR FIRST MI
OFFICEHOLDER
ronell
OFFICE USE ONLY
NAME.........................
L.
.................. I ..............................
Dale Received
NICKNAME LAST SUFFIX
Smith
M�IEOWERM)
4 CANDIDATE"
ADDRESS " PO Sox; APT / SUITE CITY, STATE: ZIP CODE
OFFICEHOLDER
JUL 15 2021
MAILING
PO Box 764, Colleyville, TX 76034
- ADDRESS
OFFICE CiTY SECRETARY
Change of Address
5 CANDIDATE/
AREA CODE PHONE NUMBER EXTENSION
D t Hand -delivpred or Dale Postmarked
OFFICEHOLDER
(817 991-2006
;& 1 OT
PHONE
0
I
Raceip Amount S
6 CAMPAIGN
MS,'MRS!MR FIRST MI
TREASURER
Rachel V.
NAME
................................................. ...... . . . . . . . . . . . . . . 11
Date Processed
NICKNAME LAST SUFFIX
Smith
Date Imaged
7 CAMPAIGN
STREET ADDRESS (NO PC BOX PLEASE): APT ,SUIT--#; CITY;
-7777
STATE; ZIP CODE
TREASURER
ADDRESS
208 Donley court
southlake, Tx 76092
(Residence or Business)
8 CAMPAIGN
AREA CODE PHONE NUMBER -EXTENSION
TREASURER
PHONE
(972- 24Y - 5736
9 REPORT TYPE
F—I January 15 El 30th day before election Runoff
E-11 15th day after campaign
treasurer appointment
fOfficenolder Only)
July 15 8th day before election Exceeded Modified
Final Report Attach 310H - FR)
Reporting Limit
10 PERIOD
Month Day Year Month
Day Year
COVERED
01 2021 THROUGH 07
15 2021
11 ELECTION
ELECTION DATE ELECTION TYPE
71 Pnmary F71 Runoff Other
Month Day Year Description
05 / 04 / 2021 11 General Special
12 OFFICE
OFFICE HELD (if any) 13 OFFICE SOUGHT (if known)
City council Place 4
14 NOTICE FROM
THIS BOX IS FOR NOTICE OF POL171CAL CONTRIBUTIONS ACCEPTED OR POLITICAL EXPENDITURES MADE BY POLITICAL COMMITTEES TO SUPPORT
POLITICAL
THE CANDIDATE 1OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATE'S OR OFFICEHOLDER'S KNOWLEDGE OR
CONSENT. CANDIDATES AND OFFICEHOLDERS ARE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY
RECEIVE NOTICE OF SUCH EXPENDITURES.
COMMITTEE(S)
I
COMMITTEE TYPE j COMMITTEE NAME
COMMITTEE ADDRESS
GENERAL
Additional Pages
01 SPECIFIC COMMITTEE CAMPAIGN TREASURER NAME
COMMITTEE CAMPAIGN TREASURER ADDRESS
h--
GO TO PAGE 2
Forms provided by Texas Ethics Commission www. ethics. state. tx. us
Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
CANDIDATE / OFFICEHOLDER FORM C/OH
COVER SHEET PG 2
CAMPAIGN FINANCE REPORT
15 C/OH NAME
16 Filer ID (Ethics Commission Filers)
17 CONTRIBUTION
1. TOTAL UNITEMIZED POLITICAL CONTRIBUTIONS (OTHER THAN
TOTALS
PLEDGES, LOANS, OR GUARANTEES OF LOANS, OR
$
N/A
CONTRIBUTIONS MADE ELECTRONICALLY)
1 TOTAL POLITICAL CONTRIBUTIONS
$
(OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS"
N/A
EXPENDITURE
TOTALS
TOTAL UNITEMIZED POLITICAL EXPENDITURE.
$
N/A
4. TOTAL POLITICAL EXPENDITURES i $ 15th
CONTRIBUTION I I
BALANCE 5, TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY $ $1,527.57
OF REPORTING PERIOD
OUTSTANDING 6, TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
LOAN TOTALS LAST DAY OF THE REPORTING PERIOD 1 $ 00.00
18 SIGNATURE 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,
DocuSigned by:
—56
Signature of Candidate or Officeholder
Please complete either option below:
�ray PO AMY SHELLEY
Notary Public, State of Texas
(
zv - =
Comm. Expires 12-02-2023 1) Affidavit Notary ID 12478110-5
NOTARY STAMP/SEAL DocuSigned by:
S
Sworn to and subscribed before me by owb I R this the15th
f—rFE101=49652456
to certify which, witness my hand and5eal of office.
Signature officer au inistering oath Printed (J6e of officer adminijering oath
(2) Unsworn Declaration
day of 3uly
CAAM:5e
Title of officer administerjrA oath
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
Executed in County, State of on the day of 20
(month) (year)
Signature of Candidate/Officeholder (Declarant)
Forms provided by Texas Ethics Commission www.ethics.state,tx.us Revised 811712020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
SUBTOTALS - C/OH FORM C/OH
COVER SHEET PG 3
19
FILER NAME
20 Filer ID (Ethics Commission Filers)
21
SCHEDULE SUBTOTALS
NAME OF SCHEDULE
SUBTOTAL
AMOUNT
SCHEDULEAl:
MONETARY POLITICAL CONTRIBUTIONS
$
2.
SCHEDULEA2:
NON -MONETARY (IN -KIND) POLITICAL CONTRIBUTIONS
$
3.
SCHEDULE B:
PLEDGED CONTRIBUTIONS
$
4.
SCHEDULE E:
LOANS
$
5.
SCHEDULE Fl:
POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS
$
6.
SCHEDULE F2:
UNPAID INCURRED OBLIGATIONS
$
7.
SCHEDULE F3:
PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS
$
8.
SCHEDULE F4:
EXPENDITURES MADE BY CREDIT CARD
$
9.
SCHEDULE G:
POLITICAL EXPENDITURES MADE FROM PERSONAL FUNDS
$
10.
SCHEDULE H:
PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH
$
11.
SCHEDULE 1: NON
-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS
$
12.
❑
SCHEDULE K:
INTEREST, CREDITS, GAINS, REFUNDS, AND CONTRIBUTIONS RETURNED
TO FILER
$
Forms provided by Texas Ethics Commission www, ethics state.tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
MONETARY POLITICAL • SCHEDULE Al
The Instruction Guide explains how to complete this form.
1 Total pages Schedule Al:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 Date
5 Full name of contributor ❑ out-of-state PAC (to#:
.................................................................... ........
6 Contributor address; City; State; Zip Code
7 Amount of contribution
8 Principal occupation / Job title (See Instructions)
9 Employer (See Instructions)
Date
Full name of contributor ❑ out-of-state PAC (ID#:
..................................................................................
Contributor address; City; State; Zip Code
Amount of contribution
Principal occupation / Job title (See Instructions)
Employer (See Instructions)
Date
Full name of contributor ❑ out-of-state PAC (ID#:
..................................................................................
Contributor address; City; State; Zip Code
Amount of contribution
Principal occupation / Job title (See Instructions)
Employer (See Instructions)
Date
Full name of contributor ❑ out-of-state PAC (ID#:
..................................................................................
Contributor address; City; State; Zip Code
Amount of contribution
Principal occupation / Job title (See Instructions)
Employer (See Instructions)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If contributor is out-of-state PAC, please see Instruction guide for additional reporting requirements.
Forms provided by Texas Ethics Commission www, ethics state.tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
NON -MONETARY (IN -KIND) POLITICAL SCHEDULE 2
CONTRIBUTIONS A
The Instruction Guide explains how to complete this form.
1 Total pages Schedule A2:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 TOTAL OF UNITEMIZED IN -KIND POLITICAL CONTRIBUTIONS
$
5 Date
6 Full name of contributor ❑ out-of-state PAC (ID#*
................................................................ I ...........
7 Contributor address; City; State; Zip Code
8 Amount of 1 9 In -kind contribution
Contribution $ I description
❑ Check if travel outside of Texas. Complete Schedule T.
10 Principal occupation / Job title (FOR NON -JUDICIAL) (See Instructions)
11 Employer (FOR NON-JUDICIAL)(See Instructions)
12 Contributor's principal occupation (FOR JUDICIAL)
13 Contributor's job title (FOR JUDICIAL) (See Instructions)
14 Contributor's employer/law firm (FOR JUDICIAL)
15 Law firm of contributor's spouse (if any) (FOR JUDICIAL)
16 If contributor is a child, law firm of parent(s) (if any) (FOR JUDICIAL)
Date
Full name of contributor Ej out-of-state PAC (ID#:
Amount of In -kind contribution
Contribution $ I description
.................................... I .......................
Contributor address; City; State;
Zip Code
Check if travel outside of Texas. Complete Schedule T.
Principal occupation / Job title (FOR NON -JUDICIAL) (See Instructions)
Employer (FOR NON-JUDICIAL)(See Instructions)
Contributor's principal occupation (FOR JUDICIAL)
Contributor's job title (FOR JUDICIAL) (See Instructions)
Contributor's employer/law firm (FOR JUDICIAL)
Law firm of contributor's spouse (if any) (FOR JUDICIAL)
If contributor is a child, law firm of parent(s) (if any) (FOR JUDICIAL)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If contributor is out-of-state PAC, please see Instruction guide for additional reporting requirements.
Forms provided by Texas Ethics Commission www, ethics state.tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
�l!li!ll��ill���ill��ill!!Il���ffolITFI!Irtw!rm
The Instruction Guide explains how to complete this form.
1 Total pages Schedule B:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 TOTAL OF UNITEMIZED PLEDGES
$
5 Date
6 Full name of pledger E] out-of-state PAC (ID#:
8 Amount I 9 In -kind contribution
of Pledge $ I description
...........................................................................
7 Pledger address; City; State; Zip Code
❑ Check if travel outside of Texas. Complete Schedule T.
10 Principal occupation / Job title (See Instructions)
11 Employer (See Instructions)
Date
Full name of pledger El out-of-state PAC (ID#:
Amount I In -kind contribution
of Pledge $ I description
...........................................................................
Pledger address; City; State; Zip Code
Check if travel outside of Texas. Complete Schedule T.
Principal occupation / Job title (See Instructions)
Employer (See Instructions)
Date
Full name of pledger 71 out-of-state PAC (ID#:
Amount of I In -kind contribution
Pledge $ I description
.............................................................
Pledger address; City; State; Zip Code
❑ Check if travel outside of Texas, Complete Schedule T
Principal occupation / Job title (See Instructions)
Employer (See Instructions)
Date
Full name of pledger F-I out-of-state PAC (ID#:
Amount of I In -kind contribution
Pledge $ I description
...........................................................................
Pledger address; City; State; Zip Code
F]Check if travel outside of Texas. Complete Schedule T.
Principal occupation / Job title (See Instructions)
Employer (See Instructions)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If contributor is out-of-state PAC, please see Instruction guide for additional reporting requirements.
Forms provided by Texas Ethics Commission www, ethics state.tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
LOANS
SCHEDULE E
If the requested information is not applicable,
DO NOT include this page in the report.
The Instruction Guide explains how to complete this form.
1 Total pages Schedule E:
2
FILER NAME
3 Filer ID (Ethics Commission Filers)
4
TOTAL OF UNITEMIZED LOANS
$
5
Date of loan
7 Name of lender
.............................................
8 Lender address;
❑ out-of-state PAC (ID#:
I ............ I ........................
City; State; Zip Code
9 Loan Amount
6 Is lender
10 Interest rate
a financial
Institution?
11 Maturity date
Y N
12
Principal occupation / Job title (See Instructions)
13 Employer (See Instructions)
14
Description of Collateral
15
Check if personal funds were deposited into political
El
0 none
account (See Instructions)
16
GUARANTOR
17 Name of guarantor
19 Amount Guaranteed ($)
INFORMATION
..................................................................................
18 Guarantor address;
City; State; Zip Code
El not applicable
20
Principal Occupation (See Instructions)
21 Employer (See Instructions)
Date of loan
Name of lender
............................. .......................
Lender address;
E] out-of-state PAC (ID#:
I ............................
City; State; Zip Code
Loan Amount ($)
Is lender
Interest rate
a financial
Institution?
Maturity date
Y N
Principal occupation / Job title (See Instructions)
Employer (See Instructions)
Description of Collateral❑
Check if personal funds were deposited into political
El none
account (See Instructions)
GUARANTOR
Name of guarantor
Amount Guaranteed ($)
INFORMATION
..................................................................................
Guarantor address;
City; State; Zip Code
El not applicable
Principal Occupation (See Instructions)
Employer (See Instructions)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
If lender is out-of-state PAC, please
see Instruction guide for additional reporting requirements.
Forms provided by Texas Ethics Commission www, ethics state.tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
Mr4r.TTDTffW=V*
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense
Event Expense Loan Repayment/Reimbursement
Solicitation/Fundraising Expense
Accounting/Banking
Fees Office Overhead/Rental Expense
Transportation Equipment & Related Expense
Consulting Expense
Food/Beverage Expense Polling Expense
Travel In District
Contributions/Donations Made By
Gift/Awards/Memorials Expense Printing Expense
Travel Out Of District
Candidate/Officeholder/Political Committee
Legal Services Salaries/Wages/Contract Labor
Other (enter a category not listed above)
Credit Card Payment
The Instruction Guide explains how to complete this form.
1 Total pages Schedule Fl:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 Date
5 Payee name
6 Amount
7 Payee address;
City; State; Zip Code
8
PURPOSE
OF
EXPENDITURE
(a) Category (See Categories listed at the top of this schedule)
(b) Description
(C) Check if travel outside of Texas, Complete Schedule T.
El Check if Austin, TX, officeholder living expense
9 Complete ONLY if direct
Candidate / Officeholder name
Office sought Office held
expenditure to benefit C/OH
Date
Payee name
Amount
Payee address;
City; State; Zip Code
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
OF
EXPENDITURE
F-1 Check if travel outside of Texas. Complete Schedule T
F-1 Check if Austin, TX, officeholder living expense
Complete ONLY if direct
Candidate / Officeholder name
Office sought Office held
expenditure to benefit C/OH
Date
Payee name
Amount
Payee address;
City; State; Zip Code
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
OF
EXPENDITURE
E] Check if travel outside of Texas. Complete Schedule T
Check if Austin, TX, officeholder living expense
Complete ONLY if direct
Candidate / Officeholder name
Office sought Office held
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us
Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
Unug-alsom
EXPENDITURE CATEGORIES FOR BOX 10(a)
Advertising Expense
Event Expense
Loan Repayment/Reimbursement
Solicitation/Fundraising Expense
Accounting/Banking
Fees
Office Overhead/Rental Expense
Transportation Equipment & Related Expense
Consulting Expense
Food/Beverage Expense
Polling Expense
Travel In District
Contributions/Donations Made By
Gift/Awards/Memorials Expense
Printing Expense
Travel Out Of District
Candidate/Officeholder/Political Committee
Legal Services
Salaries/Wages/Contract Labor
Other (enter a category not listed above)
The Instruction Guide explains how to complete this form.
1
Total pages Schedule F2:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4
TOTAL OF UNITEMIZED UNPAID INCURRED OBLIGATIONS
$
5
Date
6 Payee name
7
Amount
8 Payee address; City; State; Zip Code
9
TYPE OF
F-1 Political Non -Political
EXPENDITURE
10
(a) Category (See Categories listed at the top of this schedule)
(b) Description
PURPOSE
OF
EXPENDITURE
(C) Check if travel outside of Texas. Complete Scheduler ❑ Check if Austin, TX, officeholder living expense
11 Complete ONLY if direct Candidate / Officeholder name Office sought
expenditure to benefit C/OH
Office held
Date
Payee name
Amount
Payee address;
City; State; Zip Code
TYPE OF
EXPENDITURE
Political Non -Political
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
OF
EXPENDITURE
ElCheck if travel outside of Texas. Complete Schedule T
Check if Austin, TX, officeholder living expense
Complete ONLY if direct Candidate f Officeholder name Office sought
expenditure to benefit C/OH
Office held
Forms provided by Texas Ethics Commission www, ethics state tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
PURCHASE OF INVESTMENTS MADE SCHEDULE F3
FROM POLITICAL CONTRIBUTIONS
If the requested information is not applicable, DO NOT include this page in the report.
The Instruction Guide explains how to complete this form.
I Total pages Schedule F3:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 Date
5 Name of person from whom investment is purchased
................................................................................................................................
6 Address of person from whom investment is purchased; City; State; Zip Code
7 Description of investment
8 Amount of investment ($)
Date
Name of person from whom investment is purchased
................................................................. I ....................................................
Address of person from whom investment is purchased; City; State; Zip Code
Description of investment
Amount of investment ($)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www, ethics state.tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
EXPENDITURES MADE BY CREDIT CARD SCHEDULE F4
If the requested information is not applicable, DO NOT include this page in the report.
EXPENDITURE CATEGORIES FOR BOX 10(a)
Advertising Expense Event Expense Loan Repayment/Reimbursement Solicitation/Fundraising Expense
Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment & Related Expense
Consulting Expense Food/Beverage Expense Polling Expense Travel In District
Contributions/Donations Made By Gift/Awards/Memorials Expense Printing Expense Travel Out Of District
Candidate/Officeholder/Political Committee Legal Services Salaries/Wages/Contract Labor Other (enter a category not listed above)
The Instruction Guide explains how to complete this form.
1 Total pages Schedule F4:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 TOTALOF UNITEMIZED EXPENDITURES CHARGED TOACREDIT CARD
$
5 Date
6 Payee name
7 Amount
8 Payee address; City; State; Zip Code
9 TYPE OF
Political Non -Political
EXPENDITURE
10
(a) Category (See Categories listed at the top of this schedule)
(b) Description
PURPOSE
OF
EXPENDITURE
(c) F-1 Check if travel outside of Texas. Complete Schedule T F-1 Check if Austin, TX, officeholder living expense
11 Candidate / Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/OH
Date
Payee name
Amount
Payee address; City; State; Zip Code
TYPE OF
EXPENDITURE
Political Non -Political
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
OF
EXPENDITURE
F-1 Check if travel outside of Texas. Complete Schedule T. F-1 Check if Austin, TX, officeholder living expense
Candidate / Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
POLITICAL EXPENDITURES MADE FROM SCHEDULE G
PERSONALFUNDS
If the requested information is not applicable, DON T include this page in the report.
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense
Event Expense
Loan Repayment/Reimbursement
Solicitation/Fundraising Expense
Accounting/Banking
Fees
Office Overhead/Rental Expense
Transportation Equipment & Related Expense
Consulting Expense
Food/Beverage Expense
Polling Expense
Travel In District
Contributions/Donations Made By
Gift/Awards/Memorials Expense
Printing Expense
Travel Out Of District
Candidate/Officeholder/Political Committee
Legal Services
Salaries/Wages/Contract Labor
Other (enter a category not listed above)
Credit Card Payment
The Instruction Guide explains
how to complete this form.
1
Total pages Schedule G:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4
Date
5 Payee name
6
Amount
7 Payee address;
City; State; Zip Code
Reimbursement from
political contributions
intended
8
(a) Category (See Categories listed at the top of this schedule)
(b) Description
PURPOSE
OF
EXPENDITURE
(c) Check if travel outside of Texas. Complete Schedule T
Check if Austin, TX, officeholder living expense
9 Candidate / Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/01-1
Date I Payee name
Amount ($) Payee address; City; State; Zip Code
❑Reimbursement from
political contributions
intended
Category (See Categories listed at the top of this schedule) Description
PURPOSE
OF
EXPENDITURE
Check if travel outside of Texas. Complete Schedule T 1:1 Check if Austin, TX, officeholder living expense
Complete ONLY if direct Candidate / Officeholder name Office sought Office held
expenditure to benefit C/01-1
Date I Payee name
Amount ($) Payee address; City; State; Zip Code
Reimbursement from
political contributions
intended
Category (See Categories listed at the top of this schedule) Description
PURPOSE
OF
EXPENDITURE
1 0 Check iftravel outside ofTexas. Complete ScheduleT 1:1 Check if Austin, TX, officeholder living expense
Complete ONLY if direct Candidate / Officeholder name Office sought Office held
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www, ethics state tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
PAYMENT MADE FROM POLITICAL CONTRIBUTIONS
TO A BUSINESS OF C/OH SCHEDULE H
If the requested information is not applicable, DO NOT include this page in the report.
EXPENDITURE CATEGORIES FOR BOX 8(a)
Advertising Expense Event Expense Loan Repayment/Reimbursement Solicitation/Fundraising Expense
Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment & Related Expense
Consulting Expense Food/Beverage Expense Polling Expense Travel In District
Contributions/Donations Made By Gift/Awards/Memorials Expense Printing Expense Travel Out Of District
Candidate/Officeholder/PoliticaI Committee Legal Services Salaries/Wages/Contract Labor Other (enter a category not listed above)
Credit Card Payment
The Instruction Guide explains how to complete this form.
1 Total pages Schedule H:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 Date
5 Business name
6 Amount
7 Business address; City; State; Zip Code
8
(a) Category (See Categories listed at the top of this schedule)
(b) Description
PURPOSE
OF
EXPENDITURE
(c) Check if travel outside of Texas. Complete Schedule T. Check if Austin, TX, officeholder living expense
9 Complete ONLY if direct Candidate f Officeholder name Office sought Office held
expenditure to benefit C/OH
Date
Business name
Amount
Business address; City; State; Zip Code
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
OF
EXPENDITURE
Check if travel outside of Texas. Complete Schedule T. Check if Austin, TX, officeholder living expense
Complete ONLY if direct Candidate / Officeholder name Office sought Office held
expenditure to benefit C/OH
Date
Business name
Amount
Business address; City; State; Zip Code
Category (See Categories listed at the top of this schedule)
Description
PURPOSE
OF
EXPENDITURE
❑ Check iftravel outside ofTexas. Complete Schedule T. ❑ Check if Austin, TX, officeholder living expense
Complete ONLY if direct Candidate / Officeholder name Office sought Office held
expenditure to benefit C/OH
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state,tx.us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
NON -POLITICAL EXPENDITURES
MADE FROM POLITICAL CONTRIBUTIONS SCHEDULE
The Instruction Guide explains how to complete this form.
1 Total pages Schedule 1:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 Date
5 Payee name
6 Amount
7 Payee address; City State Zip Code
8
(a)Category (See instructions for examples of acceptable
(b) Description (See instructions regarding type of information
PURPOSE
categories.)
required.)
OF
EXPENDITURE
Date
Payee name
Amount
Payee address; City State Zip Code
Category (See instructions for examples of acceptable
Description (See instructions regarding type of information
PURPOSE
categories.)
required.)
OF
EXPENDITURE
Date
Payee name
Amount
Payee address; City State Zip Code
PURPOSE
Category (See instructions for examples of acceptable
Description (See instructions regarding type of information
OF
categories.)
required.)
EXPENDITURE
Date
Payee name
Amount
Payee address; City State Zip Code
Category (See instructions for examples of acceptable
Description (See instructions regarding type of information
PURPOSE
categories.)
required.)
OF
EXPENDITURE
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www, ethics state tx. us Revised 8/17/2020
DocuSign Envelope ID: F08E377C-9600-4B19-94B6-EB65E835D073
INTEREST, CREDITS, GAINS, REFUNDS, AND
CONTRIBUTIONS RETURNED TO • SCHEDULE K
If the requested information is not applicable, DO NOT include this page in the report. I
The Instruction Guide explains how to complete this form.
1 Total pages Schedule K:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 Date
5 Name of person from whom amount is received
........................................................................
6 Address of person from whom amount is received;
City;
........................
State; Zip Code
8 Amount
7 Purpose for which amount is received
Check if political contribution returned to filer
Date
Name of person from whom amount is received
........................................................................
Address of person from whom amount is received;
City;
........................
State; Zip Code
Amount
Purpose for which amount is received
Check if political contribution returned to filer
Date
Name of person from whom amount is received
........................................................................
Address of person from whom amount is received;
City;
........................
State; Zip Code
Amount
Purpose for which amount is received
Check if political contribution returned to filer
Date
Name of person from whom amount is received
........................................................................
Address of person from whom amount is received;
City;
........................
State; Zip Code
Amount
Purpose for which amount is received
Check if political contribution returned to filer
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 8/17/2020
000u@gnEnvelope ID: r08E377C-90UO-4a19-94a0-Eo05E835oOr3
IN -KIND CONTRIBUTIONS OR POLITICAL EXPENDITURES SCHEIDULFE T1
FOR TRAVEL OUTSIDE OF TEXAS
If the requested information is not applicable, DO NOT include this page in the report.
The Instruction Guide explains how to complete this form.
1 Total pages Schedule T:
2 FILER NAME
3 Filer ID (Ethics Commission Filers)
4 Name of Contributor / Corporation or Labor Organization / Pledgor / Payee
5 Contribution / Expenditure reported on:
El Schedule A2 [-] Schedule B E] Schedule B(J) Schedule C2 F-] Schedule D F-] Schedule F1
E] Schedule F2 F� Schedule F4 F� Schedule G E] Schedule H Schedule COWLIC F-] Schedule B-SS
6 Dates of travel
7 Name of person(s) traveling
8 Departure city or name of departure location
9 Destination city or name of destination location
10 Means of transportation
11 Purpose of travel (including name of conference, seminar, or other event)
Name of Contributor / Corporation or Labor Organization / Pledgor / Payee
Contribution / Expenditure reported on:
[] Schedule A2 Schedule B E] Schedule B(J) Schedule C2 Schedule D F-] Schedule F1
El Schedule F2 Schedule F4 F-1 Schedule G Schedule H E] Schedule COH-UC E] Schedule B-SS
Dates of travel
Name of person(s) traveling
Departure city or name of departure location
Destination city or name of destination location
Means of transportation I
Purpose of travel (including name of conference, seminar, or other event)
Name of Contributor / Corporation or Labor Organization / Pledgor / Payee
Contribution / Expenditure reported on:
El Schedule A2 Schedule B E] Schedule B(J) E] Schedule C2 Schedule D Schedule F1
F� Schedule F2 Schedule F4 F1 Schedule G E] Schedule H Schedule COH-LIC F-] Schedule B-SS
Dates of travel
Name of person(s) traveling
Departure city or name of departure location
Destination city or name of destination location
Means of transportation
Purpose of travel (including name of conference, seminar, or other event)
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided byTexas Ethics Commission wvmwethics. otam.*us Revised8/17/2020
000u@gnEnvelope ID: r08E377C-90UO-4a19-94a0-Eo05E835oOr3
CANDIDATE/ OFFICEHOLDER REPORT:
DESIGNATION OF FINAL REPORT FORM C/OH - FR
Theinstruction Guideexplains how to complete this form.
Complete only if "Report Type" on page 1 is marked "Final Report"
2 Filer ID (Ethics Commission Filers)
|donot expect any further political contributions orpolitical expenditures inconnection with mycandidacy, | understand that
designating a report as a final report terminates my campaign treasurer appointment. | also understand that | may not accept any
campaign contributions or make any campaign expenditures without a campaign treasurer appointment on file.
Signature of Candidate / Officeholder
4 FILER WHO IS NOT AN OFFICEHOLDER
.. Complete A & B below only if you are not an officeholder.
[_] | du not have unexpended contributions orunoxpended interest orincome earned from political contributions.
[_] | have unexpended contributions orunexp*ndodinterest orincome earned from political contributions. | understand that |
may not convert unexpended mditioe| contributions urunexpended interest or income earned on political contributions to
personal use. | also understand that i must file an annual report of unexpended contributions and that | may not retain
unexpended contributions or unexpencled interest or income earned on political contributions longer than six years after
filing this final report. Further, I understand that I must dispose of unexpencled political contributions and unexpended
interest or income earned on political contributions in accordance with the requirements of Election Code, § 254.204.
Check only one:
[:::] I do not retain assets purchased with political contributions or interest or other income from political contributions.
[_] |doretain assets purchased with political contributions orinterest urother income from political contributions. |und*mtand
that 1 may not convert assets purchased with political contributions urinterest orother income from political contributions to
personal use. I also understand that I must dispose of assets purchased with political contributions in accordance with the
requirements ofElection Code, 02542O4.
5 OFFICEHOLDER
.. Complete this section only if you are an officeholder
[_] |amaware that I remain subject to filing requirements applicable to an officeholder who does not have a campaign treasurer on
file. I am also aware that I will be required to file reports of unexpencled contributions if, after filing the last required report as
an officeholder, I retain political contributions, interest or other income from political contributions, or assets purchased with
political contributions or interest or other income from political contributions.
Forms provided by Texas Ethics Commission ��ethics ��.tx.uv Revised 8/17/2020