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Form 92201 Rev. 10/2011 <br />P 0 Box 12887 <br />Austin, TX 78711-2887 <br />512-463-6334 <br />512-463-5569 <br />Uiling Fee: None <br />�11 ILINI My I MIN MCI] orM M <br />I, . do solemnly swear (or affirm) that I have not <br />directly or indirectly paid, offered, promised to pay, contributed, or promised to contribute any money or <br />thing of value, or promised any public office or employment for the giving or withholding of a vote at the <br />election at which I was elected or as a reward to secure my appointment or confirmation, whichever the <br />case may be, so help me God. <br />Position to Which Elected/Appointed: <br />City and/or County: <br />Under penalties of perjury, 1 declare that I have read the foregoing statement and that the facts stated therein <br />are true. <br />Date: <br />Signature of Officer <br />Revised 10/2011 <br />Form 2201 2 <br />