HAVE RECEIVED NO FEE NOR PROMISE OF FEE FOR SERVICES OF ANY NATURE RENDERED, OR TO BE RENDERED, IN CONNECTION WITH PARtJLE OR EXECUTIVE CLEMENCY FOR THE ABOVE NAMED PERSON. : • - r - - : • Signature Printed Name bhtt. fCQ$*'jfo TX\ c PHONE #: ' CITY STATE ZIP
I HEREBY SWEAR AND AFFIRM THAT THE ABOVE INFORMATION IS TRUE AND CORRECT, AND FURTHERMORE, I HEREBY AGREE TO IMMEDIATELY SUPPLEMENT THIS AFFIDAVIT IFANYOFTHE STATEMENTS MADE HEREIN ARE AFFECTED BY A CHANGE IN FEE AGREEMENT, OR ARRANGEMENT, OR FACTUAL CONDITIONS. V) PRINTED OR TYPED NAME U<4c irQTPfb* SIGNATURE ^ T SWORN TO AND SIJRSCRTBED BEFORE ME. THE UNDERSIGNED AUTHORITY. UNDER PENALTY OF PERJURY. ON THIS THE /£> DAY OF /4&72.C>4