Confidential Social Security Information Form - Texas Ethics Commission
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1Texas Ethics Commission
P.O. Box 12070
Austin, Texas 78711-2070
(512) 463-5800
(TDD 1-800-735-2989)
CONFIDENTIAL
SSN
FORM
SOCIAL SECURITY INFORMATION
A lobby registrant must submit this form to the Texas Ethics Commission in compliance with Tex. Fam. Code Sec.
231.302(c)(1), not as a means to register as a lobbyist. To register with the Texas Ethics Commission as a lobbyist,
you must file the LOBBY REGISTRATION (FORM REG) with a filing fee.
1
PAGE #
REGISTRANT NAME
LICENSE / ACCOUNT #
2
REGISTRANT'S
(Address / PO Box, Apt/ Suite #)
OFFICE USE ONLY
HOME ADDRESS
(City, State, Zip Code)
NOTE: The Social Security Number WILL NOT be disclosed in any public file or on any
3
SOCIAL SECURITY
public document maintained by the Texas Ethics Commission.
NUMBER
___________ - _________ - __________
Month
Day
Year
4
DATE OF BIRTH
/
/
HD / PM
5
EMPLOYER NAME
Amount
Receipt #
Legal
6
EMPLOYER'S
(Address / PO Box, Apt/ Suite #)
ADDRESS
Date Processed
(City, State, Zip Code)
Date Imaged
7
SIGNATURE
To the best of my knowledge the accompanying document is true
and correct and includes all information to be reported by me under
Chapter 231, Subchapter D, Family Code.
_____________________________________________________________
Signature of Registrant
Revised 11/30/2004
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