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FORI NQ0TRUC r I ONS , SEEBACKOFFORM
DI SCLOSURE SUMMARYPAGE
COMMI TTEE NAME (
s t b e same a s o n S t a t emen t o f Or g a n i z
I MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y o u a r e r e p o r t i n g f o r ,
( 1 ) S t a t e w i d e / L e g i s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e( 5 ) C o u n t y PAC ( 6 ) B a l l o t I s s u e l F r a n c h i s e C o mm i t t e e ( 7 ) C o u n t y / C i t y C e n t r a l C o mm i t t e e( 8 ) S u p p o r t S l a t e o f C a n d i d a t e s
SI GNATUREOF TREASURER ( o r p e r s o n f i l i n g t h i s r e p o r t )
TELEPHONE
DATE SI GNED
Ro u t i n e P e n a l t i e s Du e F o r L a t e F i l e d Re p or t s Ra n g e f r o m $ 2 0 t o $ 8 0 0
SEE I NSTRUCTI ONS ON BACK ANDCOMPLETE THE F OLL OWI NG SENTENCE :
I AM F I L I NG A
k
v q
D -Z - -
REPORT FOR AN/ A ( 1 ) ELECTI ON / ( 2 ) NON- ELECT I ON YEAR.
I n d i c a t e o n e( r e p o r t d a t e )
OCHECK I F AMENDMENTTO REPORT DATED
C h e c k i f t h i s i s f i n a l ( t e r m i n a t i o n ) r e p o r t a n d a t t a c h N o t i c e o f D i s s o l u t i o n F o r m DR- 3 .( Y o u must c o n t i n u e t o f i l e r e p o r t s u n t i l a N o t i c e o f D i s s o l u t i o n i s f i l e d . )
STATEMENT OF CASH ON HAND
CASH ON HAND a t t h e b e g i n n i n g o f t h e r e p o r t i n g p e r i o d . ( T h i s i s t h e t o t a l
o f a l l mon i e s h e l d b y t h e c o mmi t t e e . T h i s amoun t MUST b e t h esame a s t h e c a s h o n h a n d a t t h e e n d o f t h e l a s t r e p o r t i n g p e r i o d ,o r must b e z e r o i f t h i s i s f i r s t r e p o r t f i l e d . )
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
ADDTOTAL MONEY TAKEN I N THI S PERI OD
FORM i
DR- 2I DI SCLOSURE
( R e v . 0 1 / 9 8 )
REPORT
F o r O f f i c e Us e On l y
Comm. #
I n d e x e d ¢Z.A u d i t e d -
C o m p u t e r L I J I
-ULI-W
L o c a l C o mm i t t e e s , e n t e r D a t e o f E l e c t i o n
C o u n t y & L o c a l C o mm i t t e e s , e n t e r C o u n t y i nw h i c h E l e c t i o n i s h e l d
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Fo r I n s t r u c t i o n s , See Back o f Fo r m
CONTRI BUTI ONS - - MONEYTAKENI N
( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )
COMMI TTEE NAME ( Mu s t b e s ame a s on S t a t e me n t o f Or g a n i z a t i o n)
i twoat ) k
STATE CANDI DATES NOTE : I F A CONTR I BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I D E NT I F I C AT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .
CAUTI ON: Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code, p r o h i b i t s t h e u s e o f i n f o r m a t i o n c op i e d f r o m r e p o r t s an d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a ny c o mme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e es .
SCHEDULE
A MONETARY
( Re v . 0 6 / 9 7 ) RECE I PTS
CHECK T HI S BOX I FAMENDI NG. , FORM
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT v I F FORRECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECEI VED FUND-( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SER
NUMBER I NCOME
I D# Vor i s Ac I e t l
1 Z l o ( CK#t c Do ^r i l el na
$ $
l p 0 5 l A o t o 2 9 L -I D# k4 , 4~ t + W
( Z ~ Z b ` o lCK# t ~ SGI AD
t
I D#
~Z ' TE11~~CK#t~ r
Cz 6 ° ` ` o CK#~ ( Col e , 61~ t i o~(~
I D#
VZVZ o l CK# ~t f 1 S t v ; t W r , , ` . AAl e4 ~ -j
lI D#
l CK#
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Fo r I n s t r u c t i o n s , See Ba c k o f Fo r m
CONTRI BUTI ONS - - MONEYTAKEN I N( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )
COMMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g a n i z a t i o n )
SCHEDULE
A MONETARY
( Re v . 0 6 / 9 7 ) I
RECE I PTS
CHECK T HI S BOX I FAMENDI NG FORM
STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ONCOMMI TTEE) , L I S T THE PAC I D E N T I F I C AT I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD.
CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Co de , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s an d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c o mme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .
DATE
RECE I VEDPAC I D NUMBER
( i f a p p l i c a b l e )NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONS HI P AMOUNT v I F FOR
( MM/ DD/ YR) ANDPACCHECK
TO CANDI DATE'( i f a p p l i c a b l e )
RECE I VED FUND-
RAI SERNUMBER
I NCOME
~Z̀ Z~I Dt
I D#
cK#
J 1 , 1 1 1 , ; ~
_
~
~1 ' 1 7I D# _
t ' Z . Z~I D ~ CK#X221 I B C )
I D#
I Z ~ 2 9 ~ O( CK# l a t e ` o o -~' ~i r.+~25 7 5
I D# b Y , r a ~v
t j ~_
CK#
I D#
CK# X50~Z IC7~ - - -
~i WMi ' ~ ~ II D# 1 Zg
CK# 5 W . B" ~ ~~ KV
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FOR I NSTRUCT I ONS, SEE BACKOF FORM SCHEDULE
EXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT
( Re v . 0 9 / 9 7 ) EXPENDI TURES
STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLATI VECANDI DATES, L I ST THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE CHECK T HI S BOX I F
PAC CHECKNUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA AMENDI NG FORM
ETHI CS & CAMPAI GN DI SCLOSURE BOARD .
COMMI TTEE NAME ( Mu s t b e s a m e a s o n St a t e me n t o f O r g a n i z a t i o n )
f
CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNT
DATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED
EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE
( MM/ DD/ YR) AND PAC
CHECK
NUMBER
1 D# ' R d r ~ C A 4 + t l k ,pp r Ca m ,
&YwtCK#
$
r woI D#
CK#
1D#
CK#
I D#
CK#
I D#
CK#
I D#
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FOR I N S TRU C T I ON S , S E E B A C K OF FORM
C OMMI TT E E NAME( Mus t b e s a me a s o n S t a t e m e n t o f O r g a n i z a t i o n )
&u e r l t b a d & V ~ r s e w a 6
NOTE : T h i s s c h e d u l e r e p o r t s mo n e y l o a n e d t o t h e c o mmi t t e e w h i c h i s d e p o s i t e d i n t h e c o mmi t t e e a c c o u n t .
TOTAL U N PA I D LOANS FROM (LAST R EP OR T I N G P E RI OD $
PART I - MONETARY LOANS R EC E I V E D T HI S R EP OR T I N G PERI OD( O r i g i n a l s o u r c e o f l o a n , s uc h a s a b a n k , must b e s h o w n i f a t h i r d p a r t y i s
i n v o l v e d . I n c l u d e l o a n s f r o m c a n d i d a t e ' s p e r s o n a l f u n d s . )
T O T A L ( PART I )
* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mmi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e
ma k i n g a c o n t r i b u t i o n t o t h e c o mmi t t e e . R e l a t i o n s h i p mus t b e s h o w n t o t h e t h i r d d e g r e e o f
c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b y ma r r i a g e ) . ( S e e P a g e 2 o f f o r m sp a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e s a me a s c a n d i d a t e , b u t t h e r e i s n o f a m i l i a l
r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn w h e n i t a p p l i e s.
PART 1 1 - MONETARY LOAN REPAYMENTS MADE T HI S R EP OR T I N G PERI OD( L o a n s f o r g i v e n must b e r e p o r t e d o n S c h ed u l e E- - I n - k i n d Co n t r i b ut i o n s. )
T O T A L CASH REPAYMENTS ( P A RT l l )
$
F r o m S c h ed u l e E - - TOTAL LOANS FORGI VEN
$
T O T A L OUTSTANDI NG LOANS END OF REPORT PERI OD
$
( f o r S c he d u l e F )
SCHEDULE
F LOANS
( R e v . 0 8 / 9 6 ) RE C E I V E D& R EP AI D
[ ~ CHECK T HI S BOX I F
AMENDI NG FORM
D ATE
R ECE I V E DMM/ DD/ YR)
NAME AND ADDRESS OF LENDER
( I n c l u d e E n d o r s e r ' s Name, I f A p p l i c a b l e )
R EL A T I ON S H I P
TO C A N DI DA T E( I f A p p l i c a b l e * )
AMOUNT
OF LOAN
' ~ °1 X' I Mc L I ' ~ t M) 1~VW~i
$
~C~~wt ~C7- l i t i
DATE P AI D( MM/ DD/ YR)
NAME AND ADDRESS OF LENDER
( I n c l u d e E n d o r s e r ' s Name, I f A p p l i c a b l e )RE L A T I ON S H I PTO C A N DI D A T E *
I f A l i c a b l e )
AMOUNTRE PA I D
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