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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. Const. art. XVI, sl(b), amended 2001) <br /> <br />I, Mike Clausen do solemnly swear (or affIrm), that I have not directly or indirectly <br />paid, offered, promised to pay, contributed, or promised to contribute any money or <br />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 my <br />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 />/l-!)--'/() <br /> <br />Date <br /> <br /> <br />v ~ <br />MfIant's Signature <br /> <br />-r\./P~~ BoMo <br />Positton to Which Elected/Appointed <br /> <br />~/~:tL /.tttqo <br /> <br />City and/or County <br /> <br />Form No. 2201 <br />