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<br />PLEASE TYPE OR PRINT LEGIBLY <br />PROVIDE ALL REQUESTED INFORMATION <br /> <br />STATEMENT OF ELECTED/APPOINTED <br />OFFICER <br /> <br />(Pursuant ta Tex. Canst. art. XVI, f1(b), amended 2001) <br /> <br />I, Tom Campbell , do solemnly swear (or affirm), that I have not directly <br />or indirectly paid, offered, promised to pay, contributed, or promised to contribute any <br />money or thing of value, or promised any public office or employment for the giving or <br />withholding of a vote at the election at which I was elected or as a reward to secure <br />my appointment or confirmation, whichever the case may be, so help me God. <br /> <br />UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING <br />STATEMENT AND THAT THE FACTS STATED THEREIN ARE TRUE. <br /> <br />Date <br /> <br />Affiant's Signature <br /> <br />Position 1, <br />Building Codes Appeals Board <br />Position to Which Elected/Appointed <br /> <br />La Porte/Harris <br />City and/or County <br /> <br />Form No. 2201 <br />