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PLEASE TYPE OR PRINT LEGIBLY <br /> PROVIDE ALL REQUESTED INFORMATION <br /> STATEMENT OF ELECTED /APPOINTED <br /> OFFICER <br /> (Pursuant to Tex. Const. art. XVI, §1(b), amended 2001) <br /> I, Terry Bunch , do solemnly swear (or affirm), that I have not directly or <br /> 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 /> aern <br /> UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING <br /> STATEMENT AND THAT THE FACTS STATED THEREIN ARE TRUE. <br /> 2 zii <br /> Date Affi. is Signature <br /> Position 2, <br /> Building Codes Appeals Board La Porte /Harris <br /> Position to Which Elected/Appointed City and/or County <br /> Form No. 2201 <br />