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Occc Personal Affidavit

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Personal Affidavit

Each principal party as identified in the "Application for License (ADM10)" or "Disclosure of Principal Parties (ADM11)" must

complete and file this form. If space is insufficient for any answer, attach a document containing a complete answer.

First Name

Middle Name (Full)

Last Name

Other Names Used (Alias)

Mailing Address

City

State

Zip Code

SSN

Date of Birth

Current Marital Status

Unmarried

Married

Separated

Sex (Gender)

Male

Female

Licensee or Applicant Name

The undersigned affirms that all answers on the personal affidavit, employment history, personal questionnaire, and in any accompanying

statement of facts are true and complete.

Signature of Individual

Full Name of Individual (Typed or Printed)

WARNING: The TEX. PENAL CODE, Sec. 37.10 provides that providing false information to a governmental agency may be a third-degree

felony offense punishable by not more than ten (10) years in prison or nor more than one (1) year in a community correctional facility. In

addition to imprisonment, a fine of up to $10,000 may also be imposed.

The Office of Consumer Credit Commissioner obtains information from this form and certain third-party sources. With few exceptions, you

may review and correct the information we collect. To find out more about the information we collect or to make an open records

request, contact our Public Information Officer at 512-936-7622 or public.information@occc.texas.gov.

Procedures for obtaining a copy of FBI criminal history record are set forth in Title 26, Code of Federal Regulations (CFR), Section 16.30 through 16.33, or

go to the FBI website at

Office of Consumer Credit Commissioner Licensing-512-936-7605 or licensing@occc.texas.gov

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Form ADM14 ( Rev 7/16)