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17-2580 PRE -OATH Statement of Elected/Appointed fficer (8/01) Hart InterCivic <br />t�,f'�;¢s �`PLY3EASETYPE ORiPRINTrLEGIBLY ��' � g,, � �� <br />E 'p;PR01/1DE,ALL',REQUESTED INFORMATIONS <br />STATEMENT OF ELECTED/APPOINTED <br />OFFICER <br />(Pursuant to Tex. Const. art. XVI, §1(b), amended 2001) <br />, 10fiJ t R_ RJQhV , do solemnly <br />swear (or affirm), that I have not directly or indirectly paid, offered, promised to pay, <br />contributed, or promised to contribute any money or thing of value, or promised any <br />public office or employment for the giving or withholding of a vote at the election at <br />which I was elected or as a reward to secure my appointment- or confirmation, <br />whichever the case may be, so help me God. <br />UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING STATEMENT AND <br />THAT THE FACTS STATED THEREIN ARE TRUE. <br />June 28, 2004 <br />Date <br />C'nukzo i'mOmhPA D At,hJ +t Si <br />Position to Which Elected/Appointed <br />Form No.2201 <br />City and/or County <br />