HomeMy WebLinkAboutVaughn, Blake Correction/Amendment Affidavit July 15th 2023 CORRECTION/AMENDMENT AFFIDAVIT
•
FOR CANDIDATE/OFFICEHOLDER FORM COR-C/OH
1 Filer ID(Ethics Commission Filers) 2 Total pages filed:
OFFICE USE ONLY
3 CANDIDATE/ MS/MRS/MR FIRST MI Date
OFFICEHOLDER J 99 `t®t !lAAAtt !l1999 ��
Mr Blake
JUL 18 2023 i
NICKNAME LAST SUFFIX
Vaughn CITY SF RETARY
4 ORIGINAL REPORT ❑ January 15 pi Runoff ❑ Final report Date Hand-delivered or Date Postmarks
TYPE ❑x July 15 I I Exceeded modified reporting 5113 P^ti v I cv
limit Receipt# Amount$
❑ 30th day before election Other(specify)
I�I 15th day after treasurer
❑ 8th day before election I 1 appointment(officeholder only)
Date Processed
5 ORIGINAL PERIOD Month Day Year Month Day Year
COVERED Date Imaged
1 / 1 / 23 THROUGH 6 / 30 / 23 -Z g -jz,3
6 EXPLANATION OF CORRECTION
Selected wrong report type.Selected January 15 when it was for the July 15 report.
7 SIGNATURE I swear,Or affirm, under penalty of perjury,that this corrected report is true and correct.
Check ONLY if applicable:
❑ Semiannual reports: I swear, or affirm,that the original report was made in good faith and without an intent to
mislead or to misrepre-sent the information contained in the report.
1-1 date
reports: I swear, or affirm,that I am filing this corrected report not later than the 14th business day after the
date I learned that the report as originally filed is inaccurate or incomplete. I swear, or affirm,that any error or
omission in the report as originally filed was made in good faith.
- Signature of Candidate/Officeholder
Please complete either option below:
(1)Affidavit
NOTARY STAMP/SEAL
Sworn to and subscribed before me by this the day of
20 ,to certify which,witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
OR
(2)Unsworn Declaration
My name is Blake Vaughn , and my date of birth is
My address is 8109 Belmont Ct. , North Richland Hills, TX , 76182 , USA
(street) (city) (state) (zip code) (country)
Executed in Tarrant County,State of Texas ,on the 18 ay of July ,20 23
onth) (year)
Signature f Candidate/Officeholder(Declarant) •
Remember To Attach Any Part Of The Campaign Finance Report Form Needed To Report And Explain Corrections
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 4/16/2021
CORRECTION/AMENDMENT AFFIDAVIT FOR CANDIDATE/OFFICEHOLDER
All Reports: Afiler who files a corrected report must submit a correction affidavit. The affidavit must identify
the information that has changed.
Reports filed with Texas Ethics Commission: A corrected report (other than a report due 8 days before
an election) filed with the Ethics Commission after its due date is not considered late for purposes of
late-filing penalties if: (1) any error or omission in the report as originally filed was made in good faith, and
(2) the person filing the report files a corrected report and a good-faith affidavit not later than the 14th
business day after the date the person learns that the report as originally filed is inaccurate or
incomplete.
Semiannual Reports: A semiannual report (due January 15 or July 15) that is amended/corrected before
the eighth day after the original report was filed is considered to have been filed on the date the original
report was filed. A semiannual report that is amended/corrected on or after the eighth day after the original
report was filed is considered to have been filed on the date the original report was filed if: (1) the
amendment/correction is made before any complaint is filed with regard to the subject of the
amendment/correction; and (2) the original report was made in good faith and without intent to mislead or
misrepresent the information contained in the report.
Attach additional pages as necessary.
INSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond to the numbered boxes on the other side.
1.Filer ID.If you file with the Ethics Commission,you should have received a letter acknowledging receipt of your
campaign treasurer appointment and assigning you a Filer ID. Put that number in this box. If you do not file with the
Ethics Commission,skip this box.
2.Total Pages Filed.After completing this form and any attachments, count the number of pages. Enter that
number in this box. Each side of a two-sided form counts as a page. In other words, this form is two pages.
3.Candidate/Officeholder Name. Put your full name here. Enter your name in the same way as on the report you
are correcting.
4.Original Report Type. Mark the type of report you are correcting.
5.Original Period Covered.Enter the period covered by the report you are correcting. The year is important because
filers sometimes correct reports years after filing the original.
6.Explanation of Correction. Attach any part of the campaign finance report form needed to report and explain
corrections. Explain why there was an error on the original report. Also explain what information is being corrected
and how the new information is different from the information on the original report. (Use additional pages if you
need more space.) You may also use this area to request a waiver or reduction of a late-filing penalty and state the
basis of your request.
7.Signature. If you are using the paper form, fill this section out by hand after you finish the rest of this report. You
have the option to either: (1)take the completed form to a notary public where you will sign above the first line that
says"Signature of Candidate/Officeholder" (an electronic signature is not acceptable) and your signature will be
notarized, or(2)sign above both lines that say"Signature of Candidate/Officeholder(Declarant)" (an electronic
signature is not acceptable), and fill out the unsworn declaration section.
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Revised 4/16/2021
CANDIDATE / OFFICEHOLDER FORM C/OH
CAMPAIGN FINANCE REPORT COVER SHEET PG 1
1 Filer ID(Ethics Commission Filers) 2 Total pages filed:
The C/OH Instruction Guide explains how to complete this form.
3 CANDIDATE/ MS/MRS/MR FIRST MI
OFFICEHOLDER Mr Blake J
OFFICE USE ONLY
NAME Date Received
NICKNAME LAST SUFFIX
Vaughn RECEIVED
4 CANDIDATE/ ADDRESS /PO BOX; APT/SUITE#; CITY; STATE; ZIP CODE
OFFICEHOLDER 8109 Belmont Ct North Richland Hills, TX 76182 fall 1 r7 ZO23
MAILING
ADDRESS CITY
SECRETARY
Change of Address
I'•ata.TO WI 41—>
5 CANDIDATE/ AREA CODE PHONE NUMBER EXTENSION
Date Hand-delivered or Date Postmarked
OFFICEHOLDER
PHONE (682 ) 334-4076
Receipt# Amount$
6 CAMPAIGN MS/MRS/MR FIRST MI
TREASURER Mr Jeffrey L
NAME Date Processed 1 r1.7(ata-b
NICKNAME LAST SUFFIX
Lott Date Imaged ` 7/ 1
1?be-3
7 CAMPAIGN STREET ADDRESS (NO PO BOX PLEASE); APT/SUITE#; CITY; STATE; ZIP CODE
TREASURER 1709 Signet Dr. Euless, TX 76040
ADDRESS
(Residence or Business)
8 CAMPAIGN AREA CODE PHONE NUMBER EXTENSION
TREASURER
PHONE (469 ) 236-9785
9 REPORT TYPE �( January 15 [ 30th day before election I I Runoff I { 15th day after campaign
l-( l ( treasurer appointment
rr (Officeholder Only)
riI 1 July 15 I m j 8th day before election [1 ExceededReportin Modified i Final Report(Attach C/OH-FR)
Ig
Limit
10 PERIOD Month Day f Year Month Day Year
COVERED
10 / 30 / 22 THROUGH 12 / 31 /22
11 ELECTION ELECTION DATE ELECTION TYPE
Month Day Year Primary Runoff Other
Description
5 / 6 / 23 General Special
•
12 OFFICE OFFICE HELD (if any) 13 OFFICE SOUGHT (if known)
City Council Place 5
14 NOTICE FROM THIS BOX IS FOR NOTICE OF POLITICAL CONTRIBUTIONS ACCEPTED OR POLITICAL EXPENDITURES MADE BY POLITICAL COMMITTEES TO SUPPORT
POLITICAL THE CANDIDATE I OFFICEHOLDER. THESE EXPENDITURES MAY HAVE BEEN MADE WITHOUT THE CANDIDATE'S OR OFFICEHOLDER'S KNOWLEDGE OR
CONSENT. CANDIDATES AND OFFICEHOLDERS ARE REQUIRED TO REPORT THIS INFORMATION ONLY IF THEY RECEIVE NOTICE OF SUCH EXPENDITURES.
COMMITTEE(S)
COMMITTEE TYPE COMMITTEE NAME
GENERAL COMMITTEE ADDRESS
Additional Pages
SPECIFIC COMMITTEE CAMPAIGN TREASURER NAME
COMMITTEE CAMPAIGN TREASURER ADDRESS
GO TO PAGE 2
Forms provided by Texas Ethics Com :, Reset Form cs s ,'ReSet'Page, Revised 8/17/2020
CANDIDATE / OFFICEHOLDER FORM C/OH
CAMPAIGN FINANCE REPORT COVER SHEET PG 2
15 C/OH NAME 16 Filer ID (Ethics Commission Filers)
Blake Vaughn
17 CONTRIBUTION 1. TOTAL UNITEMIZED POLITICAL CONTRIBUTIONS (OTHER THAN
TOTALS PLEDGES, LOANS,OR GUARANTEES OF LOANS,OR $
CONTRIBUTIONS MADE ELECTRONICALLY)
2. TOTAL POLITICAL CONTRIBUTIONS
(OTHER THAN PLEDGES, LOANS, OR GUARANTEES OF LOANS)
EXPAENDITURE 3. TOTAL UNITEMIZED POLITICAL EXPENDITURE.TOT
$
4. TOTAL POLITICAL EXPENDITURES $ 62.53
CONTRIBUTION 5. TOTAL POLITICAL CONTRIBUTIONS MAINTAINED AS OF THE LAST DAY
BALANCE OF REPORTING PERIOD $
OUTSTANDING 6. TOTAL PRINCIPAL AMOUNT OF ALL OUTSTANDING LOANS AS OF THE
LOAN TOTALS LAST DAY OF THE REPORTING PERIOD $
18 SIGNATURE I swear, or affirm, under penalty of perjury, that the accompanying report is true and correct and includes all information
required to be reported by me under Title 15,Election Code.
Signature of Candidate or Officeholder
Please complete either option below:
(1)Affidavit •
NOTARY STAMP/SEAL
Sworn to and subscribed before me by this the day of
20 , to certify which,witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
•OR' `
(2)Unsworn Declaration
My name is Blake Vaughn , and my date of birth is
My address is 8109 Belmont Ct , NRH ,TX 76182 , USA
•
(street) (city) (state) (zip code) (country)
Executed in Tarrant County,State of Texas ,on the 17 day of Januar ,2023 .
(mont year)
Signature of Candidate/Officeholder (Declarant)
Forms provided by Texas Ethics Comm Reset Form Reset
Reset Page Revised 8/17/2020
SUBTOTALS - C/OH FORM C/OH
COVER SHEET PG 3
19 FILER NAME 20 Filer ID(Ethics Commission Filers)
Blake Vaughn
21 SCHEDULE SUBTOTALS SUBTOTAL
NAME OF SCHEDULE AMOUNT
1. SCHEDULE Al: MONETARY POLITICAL CONTRIBUTIONS $
•
2. SCHEDULE A2: NON-MONETARY(IN-KIND)POLITICAL CONTRIBUTIONS $
3. SCHEDULE B: PLEDGED CONTRIBUTIONS $
4. SCHEDULE E: LOANS $
5. SCHEDULE F1: POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS $
6. SCHEDULE F2: UNPAID INCURRED OBLIGATIONS $
7• SCHEDULE F3: PURCHASE OF INVESTMENTS MADE FROM POLITICAL CONTRIBUTIONS $
8. SCHEDULE F4: EXPENDITURES MADE BY CREDIT CARD $ 62.53
9. SCHEDULE G: POLITICAL EXPENDITURES MADE FROM PERSONAL FUNDS $
10. SCHEDULE H: PAYMENT MADE FROM POLITICAL CONTRIBUTIONS TO A BUSINESS OF C/OH $
11. SCHEDULE I: NON-POLITICAL EXPENDITURES MADE FROM POLITICAL CONTRIBUTIONS $ •
12. SCHEDULE K: INTEREST, CREDITS, GAINS, REFUNDS,AND CONTRIBUTIONS RETURNED $
TO FILER
Forms provided by Texas Ethics Commit ,stat Revised 8/17/2020
Reset Form 1 Reset Page
EXPENDITURES MADE BY CREDIT CARD SCHEDULE F4
If the requested information is not applicable, DO NOT include this page in the report.
EXPENDITURE CATEGORIES FOR BOX 10(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 Travel In District
Contributions/Donations Made By Gift/Awards/Memorials Expense Printing Expense Travel Out Of District
Candidate/Officeholder/Political Committee Legal Services Salaries/Wages/Contract Labor Other(enter a category not listed above)
The Instruction Guide explains how to complete this form.
1 Total pages Schedule F4: 2 FILER NAME 3 Filer ID (Ethics Commission Filers)
Blake Vaughn
4 TOTAL OF UNITEMIZED EXPENDITURES CHARGED TOACREDIT CARD $
5 Date 6 Payee name
12/27/22 Wordpress
7 Amount ($) 8 Payee address; City; State; Zip Code
$35.18 60 29TH STREET, #343 SAN FRANCISCO 94110
9 TYPE OF f� �
EXPENDITURE !!I Political 1 i Non-Political
10 (a) Category (See Categories listed at the top of this schedule) (b) Description
PURPOSE OF Advertising Expense Website
EXPENDITURE
(c) Check if travel outside of Texas.Complete Schedule T. Check if Austin,TX,officeholder living expense
11 Candidate/Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/OH Blake Vaughn City Council Place 5 City Council Place 5
Date Payee name
12/1/22 Google
Amount ($) Payee address; City; State; Zip Code
$27.35 1600 AMPHITHEATRE PKWY Mountain View CA 94043
TYPE OF
EXPENDITURE is Political [-xi Non-Political
Category (See Categories listed at the top of this schedule) Description
PURPOSE Office Overhead Email/Storage
OF
EXPENDITURE
Check if travel outside of Texas.Complete ScheduleT. Check if Austin,TX,officeholder living expense
Candidate/Officeholder name Office sought Office held
Complete ONLY if direct
expenditure to benefit C/OH Blake Vaughn City Council Place 5 City Council Place 5
ATTACH ADDITIONAL COPIES OF THIS SCHEDULE AS NEEDED
Forms provided by Texas Ethics Commiss ' ; Reset Form ate ` Reset Page Revised 8/17/2020