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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 to Tex, Canst. aI't. XVI, Sl(b), amended 2001) <br /> <br />I, <br /> <br />, do solemnly <br /> <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 /> <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 Officer's Signature <br /> <br />Position to Which Elected/Appointed City and/or County <br /> <br />Form No. 2201 <br />