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PLEASE TYPE OR PRINT LEGIBLY <br />PROVIDE ALL REQUESTED INFORMATION <br />STATEMENT OF ELECTED/APPOINTED <br />OFFICER <br />(Pu.rsuan.G to 'I'ex. Convf. art. Xti7, §I(b), aneendetl..~001) <br />I, , do solemnly swear (or affirm), that I have not <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 />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 />me God. <br />UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING <br />STATEMENT AND THAT THE FACTS STATED THEREIN AftE TR UE. <br />Date <br />Position to Which Elected <br />Form No. `L`LOI <br />Off'icer's Signature <br />City and/or County <br />` . 9 <br />