The following form must be filed with the chief clerk of the commission prior to consideration for appointment. Answer each question or request in complete detail and in writing. Sign your answers to the questions or requests and swear to the truth of your responses before a Notary Public.

Name Address City Name of District State of Texas: County of

Zip

:

    Before me, the undersigned authority of the State and County aforesaid, on this day personally appeared who desires to be appointed as director of to serve until his successor is elected or appointed.

       (1) State whether you are 18 or 21 years old (as applicable to the type of district), a resident citizen of Texas, and either own land subject to taxation in the district or are a qualified voter within the district. If applying for director of a Regional District for Water, Wastewater, and Drainage, you are not required to state whether you own land or are a qualified voter within the district. If applying for director of a Special Utility District, state whether you are a resident citizen of this state and whether you either own land subject to taxation in the district, are a user of the facilities of the district, or are a qualified voter of the district. If applying for director of a Stormwater Control District, state whether you reside within the boundaries of the proposed district, but you are not required to state whether you own land or are a qualified voter within the district.

       (2) State whether you are a developer of property in the district, related within the third degree of affinity or consanguinity to a developer of property in the district, any other member of the governing board of the district, or the manager, engineer, or attorney for the district, or other person providing professional services to the district.

       (3) State your present occupation and employment. Is this your main source of income? If not, please explain.

       (4) State whether you plan to live in the district. If you do not plan to live in the district, what are your plans for the use and disposition of the land? Not applicable if applying for director of a Regional District for Water, Wastewater, and Drainage.

       (5) Do you, or your employer, have any business or other connections with any developer of the proposed district, the attorney representing the proposed district, or the consulting engineer for the proposed district or developer? If so, please explain.

       (6) Are you aware that the district is a public entity and that by law notice of its meetings must be given and the meeting must be open to the public and its records shall be available for public inspection at all reasonable times?

       (7) Are you aware that the district is subject to the continuing supervision of the commission and will you fully cooperate with the commission?

       (8) Do you affirm that you will faithfully execute the duties of the office of director of the district of the State of Texas, and will to the best of your ability preserve, protect, and defend the constitution and laws of the United States and of this state; do you affirm that you have not directly nor indirectly paid, offered or promised to pay, contributed, nor promised to contribute any money, or valuable thing, or promised any public office or employment as a reward to secure your appointment?

    Before me, the undersigned authority, on this day personally appeared __________________ who desires to be appointed as director of ___________________________ to serve until his successor is elected or appointed, and who being by me duly sworn on his oath deposed and said that every response and statement set forth herein is true and correct.

Sworn to and subscribed before me this         day of                  , 19       .