Form ADM 14 Personal Affidavit - Texas

Form ADM14 or the "Personal Affidavit" is a form issued by the Texas Office of Consumer Credit Commissioner.

Download a PDF version of the Form ADM14 down below or find it on the Texas Office of Consumer Credit Commissioner Forms website.

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2601 N LAMAR BLVD
AUSTIN, TX 78705
PHONE: 512.936.7605
FAX: 512.936.7610
Personal Affidavit
LICENSING@OCCC.TEXAS.GOV
Each principal party as identified in the “Application for License” or “Disclosure of Principal Parties (ADM 11)” must complete
and file this form in its entirety. 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:
Email address:
Phone Number: (
)
Current Marital Status: □ Unmarried
□ Married
□ Separated
SSN
Date of Birth
Sex: □ Male
□ Female
Licensee or Applicant Name:
The undersigned affirms that all answers on the personal affidavit, employment history, personal questionnaire and in
any accompany statement of facts are true and complete.
________________________________________
_______________________________________
Signature of Individual
Typed/Printed Full Name of Individual
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 512-936-7639 or public.information@occc.state.tx.us.
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 http://www.fbi.gov/about-us/cjis/background-checks.
Form ADM14 (Rev 11/18)
Page 1 of 1
2601 N LAMAR BLVD
AUSTIN, TX 78705
PHONE: 512.936.7605
FAX: 512.936.7610
Personal Affidavit
LICENSING@OCCC.TEXAS.GOV
Each principal party as identified in the “Application for License” or “Disclosure of Principal Parties (ADM 11)” must complete
and file this form in its entirety. 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:
Email address:
Phone Number: (
)
Current Marital Status: □ Unmarried
□ Married
□ Separated
SSN
Date of Birth
Sex: □ Male
□ Female
Licensee or Applicant Name:
The undersigned affirms that all answers on the personal affidavit, employment history, personal questionnaire and in
any accompany statement of facts are true and complete.
________________________________________
_______________________________________
Signature of Individual
Typed/Printed Full Name of Individual
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 512-936-7639 or public.information@occc.state.tx.us.
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 http://www.fbi.gov/about-us/cjis/background-checks.
Form ADM14 (Rev 11/18)
Page 1 of 1
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