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<br /> <br /> <br /> <br /> <br /> PLEASE TYPE OR PRINT LEGIBLY <br /> PROVIDE ALL REQUESTED INFORMATION <br /> <br /> <br /> <br /> <br /> <br /> STATEMENT OF ELECTED/APPOINTED <br /> <br /> OFFICER <br /> (Pursuant to Tex. Const. art. XVI, §1(6), amended 2001) <br /> <br /> <br /> <br /> <br /> <br /> I, RICHARD GROSSNICKLE, do solemnly swear (or affirm), that I have not <br /> <br /> directly or indirectly paid, offered, promised to pay, contributed, or promised to <br /> contribute any money or thing of value, or promised any public office or employment <br /> <br /> for the giving or withholding of a vote at the election at which I was elected or as a <br /> reward to secure my appointment or confirmation, whichever the case may be, so help <br /> <br /> me God. <br /> <br /> <br /> UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING <br /> STATEMENT AND THAT THE FACTS STATED THEREIN ARE TR UE. <br /> <br /> <br /> <br /> <br /> <br /> Date Officer's Signature <br /> <br /> <br /> <br /> <br /> Position to Which Elected/Appointed City and/or County <br /> <br /> <br /> <br /> <br /> Form No.2201 <br /> <br /> <br /> <br /> <br /> <br /> 96, <br />