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<br />PLEASE TYPE OR PRINT LEGIBLY <br /> <br />PROVIDE ALL REQUESTED INFORMATION <br /> <br />STATEMENT OF ELECTED/APPOINTED <br />OFFICER <br /> <br />(Pursuant to Tex. Cunst. art. XVI, j1(b), amended 2001) <br /> <br />I, pe;tvz. GtU66Uh6 <br /> <br />. do solemnly swear <br /> <br />(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 STATEMENT AND <br />THAT THE FACTS STATED THEREIN ARE TRUE. <br /> <br />,'1/26/04 <br />Date <br /> <br />~ <br /> <br />La Ponte, H~ Cauntq <br />City and/or County <br /> <br />Position to Which Elected/Appointed <br /> <br />FurmNo.2201 <br /> <br />"....."..."...,,~~~ ' <br />.-" ,'. ~. \\\'''< <br />" ,\ 1\ [l,.')"'''\ <br />/ '" \ ..t.,...."'........ II I 'Ill' <br />/ ,,;' ~"" 11 ,Il,/ <br />,I ) .. ' \ .. / .I!~ <br />;: r, D ... "f I'J <br />/ .. .. 1/ <br />~ ,:1 '-" ~{{/; t~~ f~ <br />1:1 -" \: ~ <br />1 ..I If I <br />'I .~. !~,r, ::,. < <br />I, I '~. ,~. <br />~l 'I" l,a.. J" ( <br />\, ,"11 II ",. .." '. <br />~\ ! \ ,tl.UtQn~Q..!\ <br />\\\\~ '1:'111' 'f '. <br />, "-""'"-''' <br />