Carroll, Don-COH 2021-07-01 (2) CANDIDATE / OFFICEHOLDER FORM C/OH
CAMPAIGN FINANCE REPORT COVER SHEET PG 1
1 Filer ID (Ethics Commission Filers) 2 Total pages filed: 13
The C/OH Instruction Guide explains how to complete this form.
3 CANDIDATE/ MS/MRS/MR FIRST MI
OFFICE USE ONLY
OFFICEHOLDER Mr Don R
NAME
Date Received
NICKNAME LAST SUFFIX
Carroll Jr 7/ 1 l 2 k
4 CANDIDATE/ ADDRESS /PO BOX, APT/SUITE#. CITY; STATE; ZIP CODE
OFFICEHOLDER Coppell, Texas 75019 trnft14114
MAILING
ADDRESS P_ . °
Change of Address �J
5 CANDIDATE/ AREA CODE PHONE NUMBER EXTENSION
Date Hand-delivered or Date Postmarked
OFFICEHOLDER
PHONE
Receipt # Amount $
6 CAMPAIGN MS/MRS/MR FIRST MI
TREASURER Mr Don R
NAME Date Processed
NICKNAME LAST SUFFIX
Carroll Jr Date Imaged
7 CAMPAIGN STREET ADDRESS (NO PO BOX PLEASE); APT/SUITE#; CITY: STATE; ZIP CODE
TREASURER Coppell, Texas 75019
ADDRESS
(Residence or Business)
8 CAMPAIGN AREA CODE PHONE NUMBER EXTENSION
TREASURER
PHONE
9 REPORT TYPE January 15 30th day before election Runoff 15th day after campaign
I............: ,.,...,.,__. _...,.,.,,.. treasurer appointment
(Officeholder Only)
ri July 15 n 8th day before election n Exceeded Modified •1 Final Report(Attach C/OH-FR)
Reporting Limit
10 PERIOD Month Day Year Month Day Year
COVERED 0527 21 07 01 21
/ / THROUGH / /
11 ELECTION ELECTION DATE ELECTION TYPE
Month Day Year Primary • Runoff Other
Description
06 / 05 / 21 General Special
12 OFFICE OFFICE HELD (if any) 13 OFFICE SOUGHT (if known)
Coppell City Council Place 3
14 NOTICE FROM THIS BOX IS FOR 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
CONSENT. CANDIDATES AND OFFICEHOLDERS ARE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY RECEIVE NOTICE OF SUCH EXPENDITURES.
COMMITTEE(S)
COMMITTEE TYPE COMMITTEE NAME
GENERAL COMMITTEE ADDRESS
Additional Pages
SPECIFIC COMMITTEE CAMPAIGN TREASURER NAME
COMMITTEE CAMPAIGN TREASURER ADDRESS
GO TO PAGE 2
Forms provided by Texas Ethics Corn Reset Form cs.s Reset Page 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)
Don Carroll
17 CONTRIBUTION 1. TOTAL UNITEMIZED POLITICAL CONTRIBUTIONS (OTHER THAN 0
TOTALS PLEDGES, LOANS, OR GUARANTEES OF LOANS, OR $
CONTRIBUTIONS MADE ELECTRONICALLY)
2. TOTAL POLITICAL CONTRIBUTIONS $ 1760.00
(OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS)
EXPETOTALS
3. TOTAL UNITEMIZED POLITICAL EXPENDITURE. $ 0
4. TOTAL POLITICAL EXPENDITURES $ 4513.69
CONTRIBUTION 5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY 0
$
BALANCE OF REPORTING PERIOD
OUTSTANDING 6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE 0
LOAN TOTALS LAST DAY OF THE REPORTING PERIOD $
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.
Vre'di
Sign ture of Candidate or Officehold
Please complete either option below:
• ���`Rrp'G ASHLEY M. OWENS
�`.. WS
?r° ,?,:.Notary Public,State of Texas
(1)Affidavit %-� ,••• +` Comm.Expires 02-24-2023
'ilo�a���` Notary ID 130128128
,
NOTARY STAMP/SEAL Cet,r-fo
r fa .this the of rSworn to and subscribed before me by 1) ( ` / u day V u I
20 certify whit a ness my hand and seal of office.
• / Wens 0413 01
Signature of officer administ- rig oath Printed name of officer administering oath Tit o -f officer administerin. i ath
OR
(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)
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Forms provided by Texas Ethics Comm j y 7' 5 /'% •.sta /j! "�/'�i°���,a/ �� ��%�%/�j/i Revised 8/17/2020
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SUBTOTALS - C/OH FORM C/OH
COVER SHEET PG 3
19 FILER NAME 20 Filer ID(Ethics Commission Filers)
Don Carroll
21 SCHEDULE SUBTOTALS SUBTOTAL
NAME OF SCHEDULE AMOUNT
1. ■ SCHEDULE A1: MONETARY POLITICAL CONTRIBUTIONS $ 1760.00
2. SCHEDULE A2: NON-MONETARY(IN-KIND)POLITICAL CONTRIBUTIONS $
3. SCHEDULE B: PLEDGED CONTRIBUTIONS $
4. SCHEDULE E: LOANS $
5. • SCHEDULE Fl: POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS $ 2150.91
6. SCHEDULE F2: UNPAID INCURRED OBLIGATIONS $
7 SCHEDULE F3: PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS $
8. • SCHEDULE F4: EXPENDITURES MADE BY CREDIT CARD $ 2362.78
9. ■ SCHEDULE G: POLITICAL EXPENDITURES MADE FROM PERSONAL FUNDS $ 2362.78
10. SCHEDULE H: PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH $
11. SCHEDULE I: NON-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS $
12. SCHEDULE K: INTEREST, CREDITS, GAINS, REFUNDS,AND CONTRIBUTIONS RETURNED $
TO FILER
Forms provided by Texas Ethics Commi ) i j/// 9 ���j/%72; stat p o ,,jr a Revised 8/17/2020
MONETARY POLITICAL CONTRIBUTIONS SCHEDULE Al
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 Al: 4
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Don Carroll
4 Date 5 Full name of contributor out-of-state PAC (ID#: ) 7 Amount of contribution ($)
Andy Fisher 200
5/30/21
6 Contributor address; City; State; Zip Code
136 Park Valley Ct, Coppell, TX 75019
8 Principal occupation /Job title (See Instructions) 9 Employer(See Instructions)
Date Full name of contributor out-of-state PAC(ID#: ) Amount of contribution ($)
Lee Simmons 200
6/5/21
Contributor address; City; State; Zip Code
421 Westlake Ct, Coppell, TX 75019
Principal occupation/Job title (See Instructions) Employer (See Instructions)
Date Full name of contributor out-of-state PAC(ID#: ) Amount of contribution ($)
6/5/21 Elizabeth Merrill 100
Contributor address; City; State; Zip Code
117 Meadowglen Cir, Coppell, TX 75019
Principal occupation/Job title (See Instructions) Employer(See Instructions)
Date Full name of contributor out-of-state PAC (ID#: ) Amount of contribution ($)
6/5/21 Todd Storch 500
Contributor address; City; State; Zip Code
739 Hammond St, Coppell, TX 75019
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.
z,'%', -POO ia// � P Oiii/ - i E i iiiForms provided by Texas Ethics Corn � ,V /'/ s st g
§ Revised 8/17/2020
MONETARY POLITICAL CONTRIBUTIONS SCHEDULE Al
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 Al: 4
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Don Carroll
4 Date 5 Full name of contributor out-of-state PAC(ID#: ) 7 Amount of contribution ($)
Gary Roden
6/5/21 100
6 Contributor address; City; State; Zip Code
130 Clover Meadow Ln, Coppell, TX 75019
8 Principal occupation /Job title (See Instructions) g Employer (See Instructions)
Date Full name of contributor out-of-state PAC(ID#: ) Amount of contribution ($)
Andy Fisher 20
6/5/21
Contributor address; City; State; Zip Code
136 Park Valley Ct, Coppell, TX 75019
Principal occupation/Job title (See Instructions) Employer (See Instructions)
Date Full name of contributor out-of-state PAC(ID#: ) Amount of contribution ($)
6/5/21 Randall Rhea 100
Contributor address; City; State; Zip Code
123 Ridgewood, Coppell, TX 75019
Principal occupation/Job title (See Instructions) Employer(See Instructions)
Date Full name of contributor out-of-state PAC(ID* ) Amount of contribution ($)
6/5/21 Nancy Yingling 20
Contributor address; City; State; Zip Code
606 Clifton, Coppell, TX 75019
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.
providedby f/%% / t / #7�j wpgafommgsoog�S st i/ 0�'e / '! Revised 8/17/2020
Forms Texas Ethics Comn �i j/�
MONETARY POLITICAL CONTRIBUTIONS SCHEDULE Al
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 Al: 4
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Don Carroll
4 Date 5 Full name of contributor out-of-state PAC (ID#: ) 7 Amount of contribution ($)
Chris & Cliff Long
6/5/21 100
6 Contributor address; City; State; Zip Code
710 S Coppell Rd, Coppell, TX 75019
8 Principal occupation /Job title (See Instructions) g Employer (See Instructions)
Date Full name of contributor out-of-state PAC(ID#: ) Amount of contribution ($)
Mary Lovell 20
6/5/21
Contributor address; City; State; Zip Code
1307 Barrington Dr, Coppell, TX 75019
Principal occupation/Job title (See Instructions) Employer (See Instructions)
Date Full name of contributor out-of-state PAC(ID#: ) Amount of contribution ($)
6/5/21 Kim Mobley 100
Contributor address; City; State; Zip Code
313 Dunlin Ln, Coppell, TX 75019
Principal occupation/Job title (See Instructions) Employer(See Instructions)
Date Full name of contributor out-of-state PAC(ID#: ) Amount of contribution ($)
6/7/21 David Caviness 250
Contributor address; City; State; Zip Code
417 Hunters Ridge Cir, Coppell, TX 75019
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 Com �� �'! '"'"� ;� ,��s st �%�/� " ' ���'i�//� Revised 8/17/2020
MONETARY POLITICAL CONTRIBUTIONS SCHEDULE Al
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 Al: 4
2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Don Carroll
4 Date 5 Full name of contributor out-of-state PAC (ID# ) 7 Amount of contribution ($)
Lydia Goulas 50
6/7/21
6 Contributor address; City; State; Zip Code
905 Crestview Dr, Coppell, TX 75019
8 Principal occupation/Job title (See Instructions) 9 Employer (See Instructions)
Date Full name of contributor out-of-state PAC (ID# 1 Amount of contribution ($)
Contributor address; City; State; Zip Code
Principal occupation/Job title (See Instructions) Employer (See Instructions)
Date Full name of contributor out-of-state PAC(ID# ) Amount of contribution ($)
Contributor address; City; State; Zip Code
Principal occupation/Job title (See Instructions) Employer(See Instructions)
Date Full name of contributor out-of-state PAC (ID#: ) Amount of contribution ($)
Contributor address; City; State; Zip Code
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 Com " �, �� ®�/s.st. /'' ' • %/, Revised 8/17/2020
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POLITICAL EXPENDITURES MADE SCHEDULE Fl
FROM POLITICAL CONTRIBUTIONS
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/Political Committee Legal Services SalariesNVages/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)
1 Don Carroll
4 Date 5 Payee name
6/7/21 Paypal
6 Amount ($) 7 Payee address; City; State; Zip Code
15.40 2211 North First St, San Jose, CA 95131
8 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE fees online contribution processing fees
OF
EXPENDITURE
(c) Check if travel outside of Texas.Complete Schedule T Check if Austin,TX, officeholder living expense
9 Complete ONLY if direct Candidate/Officeholder name Office sought Office held
expenditure to benefit C/OH
Date Payee name
6/28/21 Don Carroll
Amount ($) Payee address; City; State; Zip Code
2135.51 924 Hidden Hollow Ct, Coppell, TX 75019
Category (See Categories listed at the top of this schedule) Description
PURPOSE reimbursement exp pd from personal funds (5/28 and 7/1)
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 Payee name
Amount ($) Payee 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
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Corn r /!4 cs.s / �� / Revised 8/17/2020
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)
2 Don Carroll
4 TOTAL OF UNITEMIZED EXPENDITURES CHARGED TOA CREDIT CARD $
5 Date 6 Payee name
6/22/21 SquareSpace
7 Amount ($) 8 Payee address; City; State; Zip Code
28.15 225 Varick St, 12th floor, New York, NY 10014
9 TYPE OF
EXPENDITURE Political Non-Political
10 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE advertising expense website
OF
EXPENDITURE
(c) Check if travel outside of Texas.Complete Schedule T. Check if Austin.TX, officeholder living expense
11 Candidate/Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/OH
Date Payee name
5/28/21 PrintPlace
Amount ($) Payee address; City; State; Zip Code
2150.71 1130 Ave H East, Arlington, TX 76011
TYPE OF �""'`..
EXPENDITURE i....,;,J. I
Political Non-Political
Category (See Categories listed at the top of this schedule) Description
PURPOSE printing expense postcard mailers
OF
EXPENDITURE
Check if travel outside of Texas.Complete Schedule T. 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
genForms provided by Texas Ethics Commiss �� ;, / 0 f /%i,/i ate.r,G� / ; Revised 8/17/2020
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 SalariesNVages/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)
2 Don Carroll
4 TOTAL OF UNITEMIZED EXPENDITURES CHARGED TOACREDIT CARD $
5 Date 6 Payee name
6/9/21 Facebook
7 Amount ($) 8 Payee address; City; State; Zip Code
183.92 1 Hacker Way, Menlo Park, CA 94025
9 TYPE OF ��""
EXPENDITURE L'., Political rNon-Political
10 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE advertising expense ads
OF
EXPENDITURE
(c) Check if travel outside of Texas.Complete Schedule T Check if Austin, TX, officeholder living expense
11 Candidate/Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/OH
Date Payee name
Amount ($) Payee address; City; State; Zip Code
TYPE OF Qr�'�''"
EXPENDITURE I. Political I Non-Political
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
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 Commiss/;/� //;, v ,e/i//i �Or ate i� Revised 8/17/2020
Ov
POLITICAL EXPENDITURES MADE FROM
PERSONAL FUNDS SCHEDULE G
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/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)
1 Don Carroll
4 Date 5 Payee name
6/27/21 Bank of America
6 Amount ($) 7 Payee address; City; State; Zip Code
1666.66 100 North Tryon St, Charlotte, NC 28255
Reimbursement from
V political contributions
intended
8 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE credit card payment
OF p y
EXPENDITURE
(c) Check if travel outside of Texas.Complete Schedule T Check if Austin, TX, officeholder living expense
9 Candidate/Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/OH
Date Payee name
6/27/21 Bank of America
Amount ($) Payee address; City; State; Zip Code
696.12 100 North Tryon St, Charlotte, NC 28255
Reimbursement from
political contributions
intended
Category (See Categories listed at the top of this schedule) Description
PURPOSE credit card payment
OF P y
EXPENDITURE
Check if travel outside of Texas.Complete Schedule T. Check if Austin,TX, officeholder living expense
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
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. 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 Coml Reset Form cs s Reset Page Revised 8/17/2020
CANDIDATE / OFFICEHOLDER REPORT:
DESIGNATION OF FINAL REPORT FORM C/OH - FR
The Instruction Guide explains how to complete this form.
•• Complete only if "Report Type" on page 1 is marked "Final Report" ••
1 C/OH NAME 2 Filer ID (Ethics Commission Filers)
Don Carroll
3 SIGNATURE
I do not expect any further political contributions or political expenditures in connection with my candidacy. I understand that
designating a report as a final report terminates my campaign treasurer appointment. I also understand that I may not accept any
campaign contributions or make any campaign expenditures without a campaign treasurer appointment on file.
S17/
re of andidate/Officehdcl
4 FILER WHO IS NOT AN OFFICEHOLDER
•• Complete A & B below only if you are not an officeholder. ••
A. CAMPAIGN FUNDS
Check only one:
rI do not have unexpended contributions or unexpended interest or income earned from political contributions.
r- I have unexpended contributions or unexpended interest or income earned from political contributions. I understand that I
may not convert unexpended political contributions or unexpended interest or income earned on political contributions to
personal use. I also understand that I must file an annual report of unexpended contributions and that I may not retain
unexpended contributions or unexpended interest or income earned on political contributions longer than six years after
filing this final report. Further, I understand that I must dispose of unexpended political contributions and unexpended
interest or income earned on political contributions in accordance with the requirements of Election Code, §254.204.
B. ASSETS
Check only one:
rI do not retain assets purchased with political contributions or interest or other income from political contributions.
r- I do retain assets purchased with political contributions or interest or other income from political contributions. I understand
that I may not convert assets purchased with political contributions or interest or other 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 of Election Code, §254.204.
Signature of Candidate
5 OFFICEHOLDER
— Complete this section only if you are an officeholder ••
I am aware 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 unexpended 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 contributio .
P /.r,
Signature of Officeholder
i
Forms provided by Texas Ethics Com i` " ',:4 i ce,- cs.s fk4o;�r ,/,,///44,e, Revised 8/17/2020
- ce'„ a ' /
............
OFFICE USE ONLY
i, ..., Date Received
i it`'� \�x:; AFFIDAVIT FOR ,1 A °
„�' 9` CANDIDATE OR OFFICEHOLDER: II I 21
\ ;-�= ELECTRONIC FILING EXEMPTION 1 t
An exemption affidavit must be submitted with each paper report. Date Hand-delivered or Date Postmarked
Beginning on January 1, 2021, a candidate or officeholder who has accepted more than
$28,420 in political contributions or made more than $28,420 in political expenditures Receipt# Amount$
in any calendar year must file all subsequent reports electronically.
Date Processed
Filer name Filer ID# Date Imaged
o,3 -A220LL I
1. I swear or affirm that I have not accepted more than $28,420 in political contributions or made
more than $28,420 in political expenditures in a calendar year.
2. I further swear or affirm that I do not use computer equipment to keep current records of political
contributions, political expenditures, or persons making political contributions to me.
3. I further swear or affirm that no person acting as my agent or consultant, and no person with whom I
contract, uses computer equipment to keep current records of political contributions, political
expenditures, or persons making political contributions to me.
4. I further swear or affirm that I understand that I am required to file my campaign finance reports
electronically if I, my agent or consultant, or a person with whom I contract exceeds $28,420 in political
contributions or political expenditures in a calendar year, or uses computer equipment to keep current
records of political contributions, political expenditures, or persons making political contributions to me.
5. I am filing this affidavit with the F1 tvA-,i.Jc t AZ- QBao,c-rreport due on -.104—y I t 20 2 1 . I
understand that this affidavit is required to be filed with each campaign finance report for which I am
claiming an exemption from electronic filing.
Please complete either option below:
(1)Affidavit
)11 j/j-,z.tf,,#;/
Signature of Filer
NOTARY STAMP/SEAL �,,,
Sworn to and subscribed before me by` JCA\CCIA—CO`l this the 1 day of S3‘A.V6,.,
20 2\ , ocertifywhic , tnessmyhandandsealofoffice. olecx
AvIvtAd
. .
Signature of officer administers ath Printed name of o icer administering oath Title of kaicer administering oath
OR
(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 Filer (Declarant)
FILERS WHO ARE EXEMPT FROM THE ELECTRONIC FILING REQUIREMENT
ARE STILL REQUIRED TO FILE CAMPAIGN FINANCE REPORTS ON PAPER
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021