Texas Ethics Commission P.O. Box 12070 Austin, Texas 787112070 (512) 4635800 (T 18007352989) CAATE FCEHOLER CAMPAG FACE REPORT FORM C/OH COVER SHEET PG 1 The C/OH nstruction Guide explains how to complete this form. 1 ACCOUT# (Ethics Commission Filers} 2 Total pages filed: 7 3 CAATE MS/MRS/MR FRST FCEHOLER AME Mr. Jon 4 CAATE FCEHOLER CKAME.AST Siegel Ml H. SUFFX FCE USE OLY OateRec;e!)ed., r" c_5., c_ :"" ::.: ARESS PO BOX; APT SUTE#: CTY; STATE; ZP COE w MALG ate Hnddelivered,Postmed ARESS : ;; "" ::1;: 0 change of address Receit # :,. Cfl 1 r5ca ATE/ t J FCEHOLER ateitocessed:::.j W PHOE! "11.J: i 6 CAMPAG TREASURER AME MS/MRS/MR FRST Ml ate maged Mrs. Suzie. CKAME.AST SUFFX Siegel 7 CAMPAG TREASURER ARESS (residence or business) STREET ARESS (O PO BOX PLEASE); APT SUTE#; CTY; STATE: ZP COE 8 CAMPAG TREASURER PHOE AREA COE PHOE UMBER EXTESO 9 REPORT TYPE KJ January 15 30th day before election Runoff July 15 8th day before election Exceeded $500 limit 15th day after campaign treasurer appointment (officeholder only) Final report (Attach COH FR) 10 PERO COVERE Month ay Year Month ay Year 10 30 / 2016 THROUGH 12/ 31 / / 2016 11 ELECTO ELECTO ATE ELECTO TYPE Month ay Year Primary Runoff X] General Special 11 / 08 /2016 12 FCE FCE HEL (if any) 13 FCE SOUGHT (if known) Tarrant County Constable Precinct 6 Tarrant County Constable Precinct 6 GOTOPAGE2 www.ethics.state.tx.us Revised 09/28/2011
Texas Ethics Commission P.O. Box 12070 Austin, Texas 787112070 (512) 4635800 (T 18007352989) CAATE FCEHOLER REPORT: SUPPORT & TOTALS FORM C/OH COVER SHEET PG 2 14 C/OH AME 16 OTCE FROM POLTCAL COMMTTEE(S) Jon H Siegel 15 ACCOUT# (Ethics Commission Filers) THS BOX S FOR OTCE POLTCAL COTRBUTOS ACCEPTE OR POLTCAL EXPETURES MAE BY POLTCAL COMMTTEES TO SUPPORT THE CAATE f FCEHOLER. THESE EXPETURES MAY HAVE BEE MAE WTHOUT THE CAATES OR FCEHOLERS KOWLEGE OR COSET. CAATES A FCEHOLERS ARE REQURE TO REPORT THS FORMATO OLY F THEY RECEVE OTCE SUCH EXPETURES. COMMTTEE TYPE COMMTTEE AME GEERAL COMMTTEE ARESS SPECFC COMMTTEE CAMPAG TREASURER AME c_ (;.) : r 0 additional pages COMMTTEE CAMPAG TREASURER ARESS + 17 COTRBUTO TOTALS 1. TOTAL POLTCAL COTRBUTOS $50 OR LESS (OTHER THA PLEGES. LOAS, OR GUARATEES LOAS), ULESS TEMZE $ 336.00 2. TOTAL POLTCAL COTRBUTOS (OTHER THA PLEGES, LOAS, OR GUARATEES LOAS) $ 2,250.00 EXPETURE TOTALS 3. TOTAL POLTCAL EXPETURES $100 OR LESS, ULESS TEMZE $ 4. TOTAL POLTCAL EXPETURES $ 1,675.00 COTRBUTO BALACE 5. TOTAL POLTCAL COTRBUTOS MATAE AS THE LAST AY REPORTG PERO $ 47,326.31 OUTSTAG LOA TOTALS 6. TOTAL PRCPAL AMOUT ALL OUTSTAG LOAS AS THE LAST AY THE REPORTG PERO $ 50,000.00 18 AFFAVT lion required to be reported by CHERYL TYLER OTARY PUBLC STATE TEXAS M1 Celnrn. &p. 0327 2019 AFFX OTARY STAMP SEAL ABOVE Sworn to and subscribed before me, by the said =J;::oc.:;n==H==S=ie"g_e"l;;., this the 13th day of J"a"n=u"a=r._y, 20 _ 1_,_7, to certify which, witness my hand and seal of office. r administering oath
SUBTOTALS C/OH FORM C/OH COVER SHEET PG 3 19 FLER AME Jon H Siegel 20 Filer (Ethics Commission Filers) 21 SCHEULE SUBTOTALS SUBTOTAL AME SCHEULE AMOUT 1. 00 SCHEULE A 1: MOETARY POLTCAL COTRBUTOS $ 2,250.00 2. 3. SCHEULE A2: OMOETARY (K) POLTCAL COTRBUTOS $ SCHEULE B: PLEGE COTRBUTOS $ 4. [!] SCHEULE E: LOAS $ 25,000.00 5. SCHEULE F1: POLTCAL EXPETURES MAE FROM POLTCAL COTRBUTOS $ 1,675.00 6. SCHEULE F2: UPA CURRE OBLGATOS $ 7. 8. 9. 10. 11. SCHEULE F3: PURCHASE VESTMETS MAE FROM POLTCAL COTRBUTOS $ SCHEULE F4: EXPETURES MAE BY CRET CAR $ SCHEULE G: POLTCAL EXPETURES MAE FROM PERSOAL FUS $ SCHEULE H: PAYMET MAE FROM POLTCAL COTRBUTOS TO A BUSESS C/OH $ SCHEULE : OPOLTCAL EXPETURES MAE FROM POLTCAL COTRBUTOS $ 12. SCHEULE K: TEREST, CRETS, GAS, REFUS, A COTRBUTOS $ RETURE TO FLER.60. r""0 c:).. c_ "= _,. :z:::. :. c.. w.f..)._, (.} : :? =: c i :;:;;.s: :s:,. Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 9/8/2015
Texas Ethics Commission P.O. Box 12070 Austin, Texas 787112070 (512)4635800 (T 18007352989) POLTCAL COTRBUTOS OTHER THA PLEGES OR LOAS SCHEULE A The nstruction Guide explains how to complete this form. 1 Total pages Schedule A: 1 2 FLER AME 3 ACCOUT # (Ethics Commission Filers) Jon H. Siegel 4 ate 5 Full name of contributor outofstate PAC (# 11/24/16 Roz Rosenthal 6 Contributor address; City; State; Zip Code 3950 Sarita Park, Fort Worth, Texas 76109 9 Principal occupation Job title (See nstructions) 110 ) 7 Amount of 8 nkind contribution contribution description (if applicable) (f travel outside of Texas, complete Schedule T) 1,000.00 Employer (See nstructions) ate Full name of contributor outofstate PAC(#:. ) William Rosenthal 11/24/16 Contributor address; City; State; Zip Code 604 E. 4th Street, Fort Worth, Texas 76102 Principal occupation Job title (See nstructions) ate Full name of contributor outofstate PAC(# ) Fort Worth Republican Women 11/24/16 Contributor address; City; State; Zip Code P.O. Box 101613, Fort Worth, Texas 76185 Principal occupation Job title (See nstructions) Amount of contribution 1,000.00 nkind contribution description (if applicable) (f travel outside of Texas. complete Schedule Tl Employer (See nstructions) Amount of contribution 250.00 nkind contribution description (if applicable) (f travel outside of Texas, complete Schedule T) Employer (See nstructions) ate Full name of contributor outofstate PAC (#: l Amount of nkind contribution Contributor address; City; State; Zip Code Principal occupation Job title (See nstructions) Employer (See nstructions) ate Full name of contributor outofstate PAC (#: ) Contributor address; City; State; Zip Code Principal occupation Job title (See nstructions) contribution description (if applicable) (f travel outside of Texas comolete Schedule Tl Amount of contribution Employer (See nstructions), ; lnkindcontrij;iution.::.description (if ai:iiil"licable): ;::=,_;., w ri ) ; 1 i. :::: (f travel outside o Texas. comotete Sdledule T) c i 1 ::. 1 ATTACH ATOAL COPES THS SCHEULE AS EEE f contributor is outofstate PAC, please see instruction guide foradditional reporting requirements. www.ethics.state.tx.us Revised 09/28/2011
Texas Ethics Commission P.O. Box 12070 Austin, Texas 787112070 (512) 4635800 (T 18007352989) LOAS SCHEULE E The nstruction Guide explains how to complete this form. 1 Total pages Schedule E: 2 FLER AME 3 ACCOUT# (Ethics Commission Filers) Jon H. Siegel 1 4 TOTAL UTEMZE LOAS: $ 5 ate of loan 7 ame of lender outofstate PAC (#: ) 9 Loan Amount 11/14/16 Jon and Suzie Siegel 25,000.00 6 s lender 8 Lender address; City; State; Zip Code 10 nterest rate a financial 0% nstitution? 6475 Crestmore Rd., Fort Worth, Texas 76116 11 Maturity date y Open 12 Principal occupation Job title (See nstructions) 13 Employer (See nstructions) Tarrant County Constable Tarrant County 14 escription of Collateral 15 Check if personal funds were deposited into political account X] none 16 GUARATOR 17 ame of guarantor 19 Amount Guaranteed FORMATO Xl XJ not applicable 18 Guarantor address; City; State; Zip Code 20 Principal Occupation (See nstructions) 21 Employer (See nstructions) ate of loan ame of lender outofstate PAC (#. ) Loan Amount s lender Lender address; City; State; Zip Code nterest rate a financial,._.,,., nstitution?. CJ, Maturity date:i y (,, ::::>: """.,.. Principal occupation Job title (See nstructions) Employer (See nstructions) (_,) _.11 escription of Collateral Check if personal funds were deposited into politiq;ol accll!jnt _.;:_ 0 none 0 \.,. GUARATOR ame of guarantor Ariitjunt Gnteed. FORMATO C.r:; not applicable Guarantor address; City; State; Zip Code. l Principal Occupation (See nstructions) Employer (See nstructions) ATTACH ATOAL COPES THS SCHEULE AS EEE f lender is outofstate PAC, please see instruction guide for additional reporting requirements.
Texas Ethics Commission P.O. Box 12070 Austin, Texas 787112070 (512) 4635800 (T 18007352989) POLTCAL EXPETURES SCHEULE F EXPETURE CATEGORES FOR BOX S(a) Advertising Expense Gift/Awards/Memorials Expense Salaries/Wages/Contract Labor Loan Repayment/Reimbursement Accounting/Banking Legal Services Solicitation/Fundraising Expense Transportation Equipment & Related Expense Consulting Expense Food/Beverage Expense Travel n istrict Contributions/onations Made By Event Expense Polling Expense Travel Out Of istrict Candidate/Officeholder/Political Committee Fees Printing Expense Office Overhead/Rental Expense OTHER (enter a category not listed above) The nstruction Guide explains how to complete this form. 1 Total pages Schedule F: 2 FLER AME 13 ACCOUT # (Ethics Commission Filers) 1 Jon H. Siegel 4 ate 5 Payee name 11/4/16 12/31/16 Murphy asica 6 Amount 7 Payee address; City; State; Zip Code 100.00 815A Brazos Street #304, Austin, Texas 78701 8 PURPOSE (a) Category (See categories listed at the top of this schedule) (b) escription (f travel outside of Texas. complete Schedule T) EXPETURE Fee Consulting Fees 9 Complete OLY if direct Candidate Officeholder name Office sought Office held ate Payee name 11/14/16 Murphy asica Amount Payee address; City; State; Zip Code 1,500.00 815A Brazos Street #304, Austin, Texas 78701 PURPOSE Category (See categories listed at the top of this schedule) escription (f travel outside of Texas, complete Schedule T) EXPETURE Fee (Reports) Consulting Fees Complete OLY if direct Candidate Officeholder name Office sought Office held ate Payee name Amount Payee address; City; State; Zip Code, 1, < c:::). ; J PURPOSE Category (See categories listed at the top of this schedule) escription (f travel outside of texas, comp lite Schedu.lll T). ::C:1,_ :r": EXPETURE,. r; Complete OLY if direct Candidate Officeholder name Office sought Office tieta q J ate Payee name U Amount Payee address; City; State; Zip Code \ C)i"; 0,,,_ f".) : c) ) PURPOSE Category (See categories listed at the top of this schedule) escription (f travel outside of Texas, complete Schedule T) EXPETURE Complete OLY if direct Candidate Officeholder name Office sought Office held ATTACH ATOAL COPES THS SCHEULE AS EEE
Texas Ethics Commission P.O. Box 12070 Austin Texas 787112070 (512) 4635800 (T 18007352989) TEREST EARE, OTHER CRETS/GAS/ REFUS, A PURCHASE VESTMETS SCHEULE K The nstruction Guide explains how to complete this form. 1 Total pages Schedule K: 1 2 FLER AME Jon Siegel 3 ACCOUT # (Ethics Commission Filers) 4 ate 5 ame of person from whom amount is received 8 Amount 10/30/16 Frost Bank 12/31/16 6 Address of person from whom amount is received; City; State; Zip Code.60 7 Purpose for which amount is received nterest Accrued ate ame 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 ate ame of person from whom amount is received Amount Address of person from whom amount is received; City; State; Zip Code. ; l""">,.,._ l J ac c_ : T :_,.. :: ::: 1 (,) ". ( ) [". _.,,,. Purpose for which amount is received. ",:,., \ :; ate ame of person from whom amount is received 1 jamaum Address of person from whom amount is received; City; State; Zip Code Purpose for which amount is received ATTACH ATOAL COPES THS SCHEULE AS EEE