Smith Semi Jan 2022CANDIDATE / OFFICEHOLDER
11 FORM C/OH
CAMPAIGN FINANCE REPORT
COVER SHEET PG I
The C/OH Instruction Guide explains how to complete this form.
1 Filer ID (Ethics Commission Filers)
2 Total pages filed.
3 CANDIDATE/
OFFICEHOLDER
MS / MRS FIRST MI
nc
V (
OEFFICE USONLY
NAME
................... ........
NICKNAME LAST SUFFIX
Dat
JAN 18 20??
17
4 CANDIDATE
ADDRESS PO BOX; PT SUITE #; CITY� STATE; ZIP CODE
OFFICEHOLDER
fo
MAILING
OFFICE OF CITY SEC;-�,rry,,o
0
ADDRESS
Co le y W � 0 I V
16v��
Change of Address
i I L
5 CANDIDATE/
OFFICEHOLDER
AREA CODE PHONE NUMBER EXTENSION
Ved
Hand -deli qQrt�p
M
PHONE
(81� 0 b
6 CAMPAIGN
TREASURER
MS / MRSN FIRST MI
Receipt If
Amount $
I
Date Processed
NAME
... ......... ---- ...... ...... ......
NICKNAME LAST SUFFIX
(�-Y-Y) "dN)
I Date Imaged
7 CAMPAIGN
TREASURER
STREET ADDRESS (NO POBOX PLEASE); APT / SUITE #: CITY;
STATE; ZIP CODE
ADDRESS
Business}(
C/
60
(Residence or
8 CAMPAIGN
AREA CODE PHONE NUMBER EXTENSION
TREASURER
PHONE
7�
41'
9 REPORT TYPE
January 15 F 30th day before election —1 Runoff
F
15th day after campaign
treasurer appointment
( Officeholder Only)
F-1 July 15 El 8th day before election Exceeded Modified
Final Report (Attach CIOH - FR)
Reporting Limit
10 PERIOD
Month Day Year Month
Day Year
COVERED
C THROUGH Cal /)(
b (3( 6 (W-
11 ELECTION
ELECTION DATE
ELECTION TYPE
El Primary D Runoff ❑ Other
Month Day Year
Description
0 General F-1 Special
05/ (14 0 1 q
12 OFFICE
HVLD (if any)...,
07 E p/ou q
13 OFFICE SOUGHT (if known)
1 1 f1c
14 NOTICE FROM
THIS BOX IS FO NOTICE OF POLITICAL CONTRIBUTIONS ACCEPTED OR POLITICAL EXPENDITURES MADE BY POLITICAL COMMITTEES TO SUPPORT
POLITICAL
THE CANDIDATE I OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATE'S OR OFFICEHOLDER'S KNOWLEDGE OR
COMMITTEE(S)
CONSENT. CANDIDATES AND OFFICEHOLDERS ARE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY
RECEIVE NOTICE OF SUCH EXPENDITURES.
COMMITTEE TYPE
COMMITTEE NAME
1:1 GENERAL
COMMITTEE ADDRESS
Additional Pages
EISPECIFIC
COMMITTEE CAMPAIGN TREASURER NAME
COMMITTEE CAMPAIGN TREASURER ADDRESS
GO TO PAGE 2
Forms provided by Texas Ethics Commission www.ethics.state,tx.us Revised 8/17/2020
CANDIDATE / OFFICEHOLDER
FORM C/OH
CAMPAIGN FINANCE REPORT COVER SHEET PG 2
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
$
CONTRIBUTIONS MADE ELECTRONICALLY)
2. TOTAL POLITICAL CONTRIBUTIONS
(OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS)
$
EXPALSENDITURE
TOT
3. TOTAL UNITEMIZED POLITICAL EXPENDITURE.
$
......
4. TOTAL POLITICAL EXPENDITURES
$ o,06
CONTRIBUTION
5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY
$
BALANCE
OF REPORTING PERIOD
OUTSTANDING
6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
$
LOAN TOTALS
LAST DAY OF THE REPORTING PERIOD
1
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.
Signature of Candidate
or Officeholder
Please complete either option below:
AMY SHELLEY
Notary Public, State of Texas
023 (1) Affidavit
Expires 12-02-2023
]J5
is Comm,
1�% Notary ID 12476110-5
NOTARY STAMP/SEAL
pp
Sworn to and subscribed before me by l this the
day
ofJ"A.AMI
, to certify which, witness my hand and seal of office.
4&3X1
J
Sign )re).f offick-W'�inistering oath Printe"a e of officer admi6tering oath
Title of officer administer; oath
(2) Unsworn Declaration
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 8/17/2020