FORM C/OH CAMPAIGN FINANCE REPORT COVER SHEET PG 1. 1 Filer ID {Ethics Commission Filers) 2 Total pages filed: ... NICKNAME LAST SUFFIX

Transcription

1 CANIATE/ FICEHOLER FORM C/OH CAMPAIGN FINANCE REPORT COVER SHEET PG 1 The C/OH Instruction Guide explains how to complete this form. 1 Filer I {Ethics Commission Filers) 2 Total pages filed: 3 CANIATE/ MS/MRS/MR FIRST Ml FICEHOLER NAME Ado_lph_us ale Received NICKNAME LAST SUFFIX Anderson 4 CANIATE/ ARESS / PO BOX; APT / SUITE #; CITY; STATE; ZIP COE FICEHOLER MAILING ARESS Change of Address 5504 Village Lane Austin, Texas CANIATE/ AREA COE PHONE NUMBER EXTENSION FICEHOLER PHONE ( 512 ) FICE USE ONLY ~tc:~l~ Io ate Hand.delivered or ate Postmarked 6 CAMPAIGN MS/MRS/MA FIRST Ml Receipt # TREASURER Elena NAME ate Processed NICKNAME LAST SUFFIX Taylor ate Imaged I Amount 7 CAMPAIGN STREET ARESS (NO PO BOX PLEASE); APT/ SUITE #; CITY; STATE; ZIP COE TREASURER ARESS {Residence or Business) 3014 W. William Cannon #1922 Austin, Texas CAMPAIGN AREA COE PHONE NUMBER EXTENSION TREASURER PHONE ( 512 ) REPORT TYPE January 15 IX] 3lh day before election Runoff July 15 8th day before elec!ion Exceeded 500 limit 15th day after campaign treasurer appointment (Olflceholder Only) F!nal Report (Attach C/OH - FA) 10 PERIO Month ay Year Month ay Year COVERE 7 / 25/ 2016 THROUGH 9 / 29 / ELECTION ELECTION ATE ELECTJON TYPE Month ay Year Primary Runo!f Other escription 11/ 8 / 2016 IX] General Special 12 FICE FICE HEL (ii any) 13 FICE SOUGHT (if known) AIS Trustee, istrict 2 GO TO PAGE 2 Forms provided by Texas Ethics Commission Revised 9/8/2015

2 CANIATE/ FICEHOLER CAMPAIGN FINANCE REPORT FORM C/OH COVER SHEET PG 2 14 C/OH NAME Adolphus Anderson 15 Filer I (Ethics Commission Fliers) 16 NOTICE FROM POLITICAL COMMITTEE(S) THIS BOX IS FOR NOTICE POLITICAL CONTRIBUTIONS ACCEPTE OR POLITICAL S MAE BY POLITICAL COMMIITEES TO SUPPORT THE CANIATE/ FICEHOLER. THESE S MAY HAVE BEEN MAE WITHOUT THE CANIATE'S OR FICEHOLER'S KNOWLEGE OR CONSENT, CANIATES AN FICEHOLERS ARE REQUIRE TO REPORT THIS INFORMATION ONLY IF THEY RECEIVE NOTICE SUCH S. COMMITTEE TYPE COMMITTEE NAME 0GENERAL OsPECIFIC COMMITTEE ARESS COMMITTEE CAMPAIGN TREASURER NAME Additional Pages COMMITTEE CAMPAIGN TREASURER ARESS 17 CONTRIBUTION TOTALS 1. TOTAL POLITICAL CONTRIBUTIONS 50 OR LESS (OTHER THAN PLEGES, LOANS, OR GUARANTEES LOANS), UNLESS ITEMIZE 0 2. TOTAL POLITICAL CONTRIBUTIONS (OTHER THAN PLEGES, LOANS, OR GUARANTEES LOANS) 0 TOTALS 3. TOTAL POLJT!CAL S 1b0 OR LESS, UNLESS ITEMIZE 0 4. TOTAL POLITICAL S 0 CONTRIBUTION BALANCE 5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINE AS THE LAST AY REPORTING PERIO 0 OUTSTANING LOAN TOTALS 6. TOTAL PRINCIPAL AMOUNT ALL OUTSTANING LOANS AS THE LAST AY THE REPORTING PERIO 0 18 AFFIAVIT MAJIGERY ELAINE HOPKINS MY Commission ENplres July 9, 2018 anying report is reported by me Signature of Candidate or Officeholder AFFIX NOTARY STAMP/SEALABOVE Sworn to and subscribed before me, by the said, to certify which, witness my hand and seal of office. day of.(>f\--t...~-:-20 l C.., this the Printed name of o cer a ministering oath Title of officer administering oath Forms provided by Texas Ethics Commission Revised 9/8/2015

3 SUBTOTALS - C/OH FORM C/OH COVER SHEET PG 3 19 FILER NAME Adolphus Anderson 20 Filer I (Ethics Commission Filers) 21 SCHEULE SUBTOTALS NAME SCHEULE 1. SCHEULEA1: MONETARY POLITICAL CONTRIBUTIONS 2. SCHEULEA2: NON-MONETARY (IN-KIN) POLITICAL CONTRIBUTIONS 3. SCHEULE B: PLEGE CONTRIBUTIONS 4. SCHEULE E: LOANS 5. SCHEULE F1: POLITICAL S MAE FROM POLITICAL CONTRIBUTIONS 6. SCHEULE F2: UNPAI INCURRE OBLIGATIONS 7. SCHEULE F3: PURCHASE INVESTMENTS MAE FROM POLITICAL CONTRIBUTIONS 8. SCHEULE F4: S MAE BY CREIT CAR 9. [lj SCHEULE G: POLITICAL S MAE FROM PERSONAL FUNS 10. SCHEULE H: PAYMENT MAE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS C/OH. 11. SCHEULE I: NON-POLITICAL S MAE FROM POLITICAL CONTRIBUTIONS 12. SCHEULE K: INTEREST, CREITS, GAINS, REFUNS, AN CONTRIBUTIONS RETURNE TO FILER SUBTOTAL AMOUNT Forms provided by Texas Ethics Comm1ss1on Revised 9/8/2015

4 MONETARY POLITICAL CONTRIBUTIONS SCHEULE A1 The Instruction Gulde explains how to complete this form. 1 Total pages Schedule A1: 2 FILER NAME 3 Filer I {Ethics Commission Filers) 4 ale 7 Amount of contribution () 5 Full name of contributor out of-slate PAC (!ci#: ) 6 Contributor address; City; State; Zip Code 8 Principal occupation / Job title (See Instructions) 9 Employer (See Instructions) ate Full name of contributor out-of-stale PAC (I/I: ' Amount of contribution () Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer {See Instructions) ate Full name of contributor out-of-state PAC (I/I: ) Amount of contribution () Contributor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) ate Amount of contribution () Full name of contributor 0 out-of-state PAC (I#: ) Contribu_tor address; City; State; Zip Code Principal occupation / Job title (See Instructions) Employer (See Instructions) ATIACH AITIONAL COPIES THIS SCHEULE AS NEEE If contributor is out of state PAC, please see Instruction guide for additional reporting requirements. Forms provided by Texas Ethics Commission Revised 9/8/2015

5 NON-MONETARY {IN-KIN) POLITICAL CONTRIBUTIONS SCHEULE A2 The Instruction Gulde explains how to complete this form. 1 Tota! pages Schedule A2: 2 FILER NAME 3 Flier I {Ethics Commission Filers) 4 TOTAL UNITEMIZE IN-KIN POLITICAL CONTRIBUTIONS 5 ate 6 Full name of contributor out-of-state PAC (I/I: I 8 Amount of 9 In-kind contribution Contribution description 7 Contributor address; City; State; Zip Code 0 Check if travel outside of Texas. Complete Schedule T. 10 Principal occupation/ Job title {FOR NON-JUICIAL)(See Instructions) 11 Employer (FOR NON-JUICIAL) (See Instructions) 12 Contributor's principal occupation (FOR JUICIAL) 13 Contributor's job title (FOR JUICIAL) (See Instructions) 14 Contributor's employer/law firm (FOR JUICIAL) 15 Law firm of contributor's spouse (if any) (FOR JUICIAL) 16 If contributor is a child, law firm of parent(s) (if any) {FOR JUICIAL) ate Full name of contributor out-ol-stata PAC (I#: I Amount of Jn-kind contribution Contribution description Contributor address; City; State; Zip Code Pr!nclpal occupation/ Job title (FOR NON-JUICIAL) {See Instructions) Check If travel outside of Texas. Complete Schedule T. Employer {FOR NON-JUICIAL){See Instructions) Contributor's prfncipal occupation (FOR JUICIAL) Contributor's job title (FOR JUICIAL) (See Instructions) Contributor's employer/law firm (FOR JUICIAL) Law firm of contributor's spouse (if any) {FOR JUICIAL) If contributor is a child, raw firm of parent(s) (if any) (FOR JUICIAL) ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE If contributor Is out-of-state PAC, please see instruction guide for additional reporting requirements. Forms provided by Texas Ethics Commission Revised 9/8/2015

6 PLEGE CONTRIBUTIONS SCHEULE B 2 FILER NAME The Instruction Gulde explains how to complete this form. 1 Total pages Schedule B: 3 Filer I (Ethics Commission Filers) 4 TOTAL UNITEMIZE PLEGES 5 ate 6 Full name of pledgor out-of state PAC (I/I: ' 8 Amount.9 In-kind contribution of Pledge description 7 Pledger address; City; State; Zip Code 10 Principal occupation/ Job title (See Instructions) 111 Employer (See Instructions) Check if travel outside of Texas. Complete Schedule T. ate Full name of pledger out-of-state PAC (I#: Amount I In-kind contribution of Pledge description Pledger address; City; State; Zip Code Prfnclpal occupation / Job title (See Instructions) I 0 Check if travel outside of Texas. Complete Schedule T. Employer (See Instructions) ate Full name of pledgor oul ol-slate PAC (J/I: I Amount of In-kind contribution Pledge description Pledgor address; City; State; Zip Code Principal occupation / Job title (See Instructions) I Check if travel outside of Texas. Complete Schedule T. Employer (See Instructions) ate Full name of pledgor out-of-slate PAC (I/I: Amount of In-kind contribution I Pledge description Pledger address; City; State; Zip Code Principal occupation / Job title (See Instructions) I Employer (See Instructions) Check if travel outside of Texas. Complete Schedule T. ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE If contributor Is out-of~state PAC, please see instruction guide for additional reporting requirements. Forms provided by Texas Ethics Commission Revised 9/8/2015

7 LOANS SCHEULE E The Instruction Gulde explains how to complete this form. 1 Total pages Schedule E: 2 FILER NAME 3 Filer! (Ethics Commission Filers) 4 TOTAL UNITEMIZE LOANS 5 ate of Joan 7 Name of lender out-of-slate PAC (I#:_ I 9 Loan Amount() 6 Is lender a flnanclal 8 Lender address; Institution? y N City: State; Zip Code - 10 Interest rate 11 Maturity date 12 Principal occupation / Job title, (See Instructions) 13 Employer (See Instructions) 14 escription of Collateral 15 Check if personal funds were deposited into political account (See Instructions) none 16 GUARANTOR 17 Nameofguarantor 19 Amount Guaranteed() INFORMATION not applicable 18 Guarantor address; City; State; Zip Code 20 Principal Occupation (See Instructions) 21 Employer (See Instructions) Op.ta of loan Name oflender out-of-stale PAC (I#: I Loan Amount() Is lender Lender address; City; State; Zip Code a financial Institution? y N Interest rate Maturity date Principal occupation / Job title (See Instructions) Employer (See Instructions) escription of Collateral none Check if personal funds were deposited into political account (See Instructions) GUARANTOR Name of guarantor Amount Guaranteed() INFORMATION Guarantor address; City; State; Zip Code not appl!cable Principal Occupation (See Instructions) Employer (See Instructions) ATIACH AITIONAL COPIES THIS SCHEULE AS NEEE If lender Is out-of-state PAC, please see instruction guide for additional reporting requirements. Forms provided by Texas Ethics Commission Revised 9/8/2015

8 POLITICAL S MAE FROM POLITICAL CONTRIBUTIONS SCHEULE F1 CATEGORIES FOR BOX 8(a) Advertising Expense Event Expense Loan RepaymenVReirnbursement So!icitalion/Fundraislng Expense Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment & Related Expense Consulting Expense Food/Beverage Expense Polling Expense Travel In istrict Contributlons/onaUons Made By GifVAwards/Memorials Expense Printing Expense Travel Out Of istrict Cand!date/Offlceho!der/Po!itical Committee legal Services Salaries/Wages/Contract Labor Other (entera category not listed above) Credit Card Payment The Instruction Guide explains how to complete this form. 1 Total pages Schedule F1: 2 FILER NAME 13 Fifer I {Ethics Commission Fliers) 4 ate 5 6 Amount () 7 Payee address; City; state; Zip Code 8 (a) Category (See Categories listed at the lop of this schedule) (b) escription 0 Check ii travel ou!side of Texas. Complete Schedule T. 0 Check ii Austin, TX, olflceholder living expense 9 Complete ONLY if direct Candidate/ Officeholder name Office sought Office held ate Amount () Payee address; City; State; Zip Code Category (See Categories listed al the top of this schedule} escription 0 Check if travel outside of Texas. Complete Schedule T. 0 Check II Austin, TX, officeholder living expense Complete ONLY!f direct Candidate/ Officeholder name Office sought Office held ate Amount () Payee address; City; State; Zip Code Category (See Categories listed al the top of this schedule) escription 0 Check If travel outside of Texas. Complete Schedule T. 0 Check if Austin, TX, officeholder living expense Complete ONLY if direct Candidate / Officeholder name Office sought Office held ATIACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission Revised 9/8/2015

9 UNPAI INCURRE OBLIGATIONS SCHEULE F2 CATEGORIES FOR BOX 10(a} Advertising Expense Event Expense Loan RepaymenVReimbursement Solicitatiort/Fundraislng Expense Accountlng/BankJng Foos Office Overhead/Rental Expense Transportation Equipment &Related Expense ConsulUng Expense Food/Beverage Expense Polling Expense Travel In istrict Contributions/onations Made By Gift/Awards/Memorials Expense Printing Expense Travel Out or istrict Candldate/Officeho!der/Polltical Committee legal Services Salaries/'Wages/Contract Labor Other (entera category not listed above) The Instruction Guide explains how to complete this form. 1 Total pages Schedule F2: 2 FILER NAME 3 Filer I (Ethics Commission Fliers) I 4 TOTAL UNITEMIZE UNPAI INCURRE OBLIGATIONS 5 ate 6 7 Amount () 8 Payee address; City; State; Zip Code 9 10 TYPE Political Non-Political (a) Category (See Categories listed al the top of this schedule) (b) escription Check if travel outside of Texas. Comple1o Schedule T. Ocheck if Austin, TX, officeholder living expense 11 Complete ONLY If direct Candidate / Officeholder name Office sought Office held ale Amount () Payee address; City; State; Zip Code TYPE Political Non-Political Category (See Categories listed at the top of this schedule) escription Check iflravel outside of Texas. Complete Schedule T. Chock If Austin, TX, o/f!coholder living expense Complete ONLY if direct Candidate I Officeholder name Office sought Office held ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Comm1ss1on Revised 9/8/2015

10 PURCHASE INVESTMENTS MAE FROM POLITICAL CONTRIBUTIONS SCHEULE F3 The Instruction Gulde explains how to complete this form. 1 Total pages Schedule F3: 2 FILER NAME 3 Filer I (Ethics Commission Filers) 4 ate 5 Name of person from whom Investment Is purchased 6 Address of person from whom investment is purchased; City; State; Zip Code 7 escription of investment 8 Amount of investment () ate Name of person from whom investment is purchased Address of person from whom investment is purchased; City; State; Zip Code escription of investment Amount of Investment () ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission Revised 9/8/2015

11 S MAE BY CREIT CAR SCHEULE F4 CATEGORIES FOR BOX 1 O(a) Advertising Expanse Event Expense Loan Repayment/Reimbursement Accounting/Banking Fees Office Overheadr'Rental Expense Consulting Expense Food/Beverage Expanse PolJ!ng Expense Contributions/onations Made By Gilt/Awards/Memorials Expense Printing Expense Candidate/Otnceholder/Political Committee Legal Services Salaries/Wages/Contract Labor 1 Total pages Schedule F4: 2 FILER NAME The Instruction Guide explalns how to complete this form. Solicitation/Fundraising Expense Transportation Equipment& Related Expanse Travel Jn istrict Travel Out or istrict Other(enlera catego,y not listed above) 3 Filer I (Ethics Commission Fliers) 4 TOTAL UNITEMIZE S CHARGE TO A CREIT CAR 5 ate 6 7 Amount () 8 Payee address; City; State; Zip Code ~ 9 10 TYPE Political 0 Non-Political (a) Category (See Categories listed at the top of this schedule) (b) escription Check if travel outside of Texas. Complete Schedule T. Check If Austin, TX, olficeholder living expense 11 Complete ONLY If direct Candidate / Officeholder name Office sought Office held ate Amount () Payee address; City; State; Zip Code TYPE Political Non-Political Category (See Categories Iisled at the lop of this schedule) escription Check if travel outside of Texas. Complete Schedule T. Ochack If Auslin, TX, officeholder living expense Complete ONLY If direct Candidate I Officeholder name Office sought Office held ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission Revised 9/8/2015

12 POLITICAL S MAE FROM PERSONAL FUNS SCHEULE G CATEGORIES FOR BOX 8(a) Advertising Expense Event Expense Loan RepaymenVRelmbursement Solicitation/Fundralsing Expense Accounting/Banking Foos Office overhead/rental Expense Transportation Equipment & Related Expense Consulting Expanse Food/Beverage Expense Polling Expense Travel In istrict Contributions/onations Made By GifVAwards/Memoriats Expanse Printing Expense Travel Out Of istrict Candidate/Officeholder/Political Committee legal Services Salaries/Wages/Contract Labor Other (entera categol)' not listed above) Credit Card Payment The Instruction Guide explatns how to complete this form, 1 Total pages Schedule G: 2 FILER NAME 4 ate 5 Adolohus Anderson 8/30/2016 Super Cheap Signs 6 Amount () 7 Payee address; City; State; Zip Code Reimburoement from 9200 Waterford Center Blvd. Suite 100 Austin, Texas pollt!cal contributions Intended I 3 Filer I (Ethics Commission Filers) 8 {a) Category (See Categories listed at the top of this schedule) (b) escription Check if travel oulsida of Texas. Complele Schedule T. Printing Expense Check if Austin, TX, offlcoholdor l!vlng expense 9 Complete ONLY if direct Candidate I Officeholder name Office sought Office held ate Amount () Payee address; City; state; Zip Code 0 Relmbursementfrom political contributions intended Category (See Categories listed at the top of this schedule) (b) escription Check if travel outside oftexas. Complete Schedulo T. Check ii Austin, TX, officeholder living exponse Complete ONLY if direct Candidate / Officeholder name Office sought Office held ate Amount () Payee address; City; State; Zip Code Reimbursement from po/ltical contributions intended ' Category (See Categories listed at!he top of this schedule) (b) escription Check if!ravel outside of Texas. Complete Schedule T. Check if Auslin, TX, officeholder living expense Complete ONLY if direct Candidate / Officeholder name Office sought Office held ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission Revised 9/8/2015

13 PAYMENT MAE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS C/OH SCHEULE H CATEGORIES FOR BOX B(a) Advertising Expense Event Expense loan Repayment'Reimbursement Solicitation/Fundraising Expense Accounting/Banking Fees Office Overhead/Rental Expense Transportation Equipment& Related Expense Consulting Expense Food/Beverage Expense Polling Expense Traver In istrict ContribuUons/onatlons Made By GifVAwards/Memorials Expanse Printing Expense Travel Out Of istrict Candidate/Officeholder/Political Committee Legal Services Salaries/Wages/Contract Labor Other (entera category not listedabove) Credit Card Payment The Instruction Gulde explains how to complete this form, 1 Total pages Schedule H: 2 FILER NAME l 3 Filer I {Ethics Commission Filers) 4 ate 5 Business name 6 Amount () 7 Business address; City; State; Zip Cade 8 (a) Category (Sae Categorias listed at the top of this schedule) (b) escription Check il1ravel oulside oftexas. Complete Schedule T. Check!I Austin, TX, officeholder living expense 9 Complete ONLY if direct Candidate / Officeholder name Office sought Office held ate - Business name Amount () Business address; City; State; Zip Code Category (Soo Categories listed al the top of this schedule) escription Check if1ravel outsido o!texas. Complala Schedule T. Check!f Austin, TX, oflicaholder living expansa Complete ONLY If direct Candidate I Offfceholder name Office sought Office held ate Business name Amount () Business address; City; State; Zip Code Category (Sea Categories listed at the top of this schedule} escription Check if travel outside of Texas. Complete Schedule T. Check if Austin, TX, offlcoholdor living expanse Complete ONLY If direct Candidate / Officeholder name Office sought Office held ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission W>Nw.ethics.state.tx.us Revised 9/8/2015

14 NON-POLITICAL S MAE FROM POLITICAL CONTRIBUTIONS SCHEULE I The Instruction Guide explains how to complete this form. 1 Total pages Schedule I: 2 FILER NAME 3 Flier J (Ethics Commission Filers) 4 ate 5 6 Amount {) 7 Payee address; City; State; Zip Code 8 (a)category {See instructions for examples of acceptable categories.) (b) escription (See instructions regarding type of fnforma!lon required.) ate Amount () Payee address; City; State; Zip Code Category (See instructions for examples of acceptable categories.) escription (See Instructions regarding typo of Information required.) ate Amount () Payee address; City; state; Zip Code Category (See lnstruct!ons for examples of acceptable categories.) escription (See instructions regarding type of information required.) ate Amount () Payee address; City; State; Zip Code Category (See instrucuons for examples of accoptable categories.) escription (See instructions regarding!ype of!nformatlon required.) ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission Revised 9/8/20i 5

15 INTEREST, CREITS, GAINS, REFUNS, AN CONTRIBUTIONS RETURNE TO FILER SCHEULE K The Instruction Guide explains how to complete this form. 1 Total pages Schedule K: 2 FILER NAME 3 Filer I (Ethics Commission Filers) 4 ate 5 Name of person from whom amount is received 8 Amount() 6 Address of person from whom amount Is received; City; State; Zip Code 7 Purpose for which amount is received Check if political contribution returned to filer ate Name of person from whom amount is received Amount () Address of person from whom amount Is received; City; State; Zip Code Purpose for which amount is received Check if politlcal contribution returned to filer ate Name of person from whom amount is received Amount () Address of person from whom amount Is received; City; State; Zip Code Purpose for which amount ls received Check If political contribution returned to filer ate Name of person from whom amount is received Amount() Address of person from whom amount is received; City; State; Zip Code ' Purpose for which amount is received Check if political contribution returned to filer ATIACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission Revised 9/8/2015

16 IN-KIN CONTRIBUTIONS OR POLITICAL S FOR TRAVEL OUTSIE TEXAS SCHEULE T The Instruction Guide explains how to complete this form. 1 Total pages Schedule T: 2 FILER NAME 3 Flier I. (Ethics Commission Filers) 4 Name of Contributor I Corporation or Labor Organization/ Pledger/ Payee 5 Contribution/ Expenditure reported on: 0 Schedule A2 Oschedule B Schedule B(J) 0 Schedule C2 Schedule Schedule F1 Schedule F2 Schedule F4 Oschedule G Oschedule H Schedule COH-UC Schedule B-SS 6 ates of travel 7 Name of person(s) traveling 8 eparture city or name of departure location 9 estination city or name of destination location 10 Means of transportation 11 Purpose of travel (including name of conference, seminar, or other event) Name of Contributor/ Corporation or Labor Organization/ Pledgor / Payee Contribution/ Expenditure reported on: 0 Schedule A2 Oschedule B Schedule B(J) Schedule C2 Schedule Schedule F1 Schedule F2 Schedule F4 Oschedule G Schedule H Schedule COH-UC Schedule 8-SS ates of travel Name of person(s) traveling eparture city or name of departure location estination city or name of destination locatlon Means of transportation Purpose of travel (including name of conference, seminar, or other event) Name of Contributor I Corporation or Labor Organization/ Pledgor / Payee Contribution/ Expenditure reported on: Schedule A2 Oschedule B Schedule B(J) Schedule C2 0 Schedule Schedule F1 Schedule F2 Schedule F4 Oschedule G Schedule H Schedule COH-UC Schedule 8-SS ates of travel Name of person(s) traveling eparture city or name of departure location estination city or name of destination location Means of transportation Purpose of travel (including name of conference, seminar, or other event) ATTACH AITIONAL COPIES THIS SCHEULE AS NEEE Forms provided by Texas Ethics Commission Revised 9/8/2015

17 CANIATE/ FICEHOLER REPORT: ESIGNATION FINAL REPORT FORM C/OH - FR The Instruction Guide explains how to complete this form. Complete only if "Report Type" on page 1 is marked "Final Report" 1 C/OH NAME 3 SIGNATURE Adolphus Anderson 2 Filer I (Ethics Commission Filers) 4 FILER WHO IS NOT AN FICEHOLER Complete A & B below only if you are not an officeholder. A. CAMPAIGN FUNS Check only one: 00 I do not have unexpended contributions or unexpended interest or income earned from political contributions. I have unexpended contributions or unexpended interest or income earned from political contributions. l understand that I may not convert unexpended political contributions or unexpended interest or income earned on political contributions to personal use. I also understand that J must file an annual report of unexpended contributions and that l may not retain unexpended contributions or unexpended interest or income earned on political contributions longer than six years after filing this final report. Further, I understand that I must dispose of unexpended political contributions and unexpended interest or income earned on political contributions in accordance with the requirements of Election Code, B. ASSETS Check only one: [XJ I do not retain assets purchased with political contributions or interest or other income from political contributions. I do retain assets purchased with political contributions or interest or other income from political contributions. l understand that I may not convert assets purchased with political contributions or interest or t e inco e fro politic l CO!)H' utions to personal use. I also understand that I must dispose of assets purchased w politic I c tribu ons in con.fat ce with the requirements of Election Code, FICEHOLER Complete this section only if you are an officeholder I am aware that I remain subject to filing requirements applicable to an officeholder who does not have a campaign treasurer on file. I am also aware that I will be required to file reports of unexpended contributions if, after filing the last required report as an officeholder, I retain political contributions, interest or other income from political contributions, or assets purchased with political contributions or interest or other income from political contributions. Signature of Officeholder Forms provided by Texas Ethics Commission Revised 9/8/2015