gorman steven1331scanned

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APR 02 2 0 0 3 2 : 3 0PM

FORI NSTRUCTI ONS, SEE BACK OF FORM

DI SCLOSURE SUMMARYPAGE

Ca n d i d a t e Na me

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( t ) S t a t e wi d e l L e g i s l a f i r e Ca n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e Pa r t y ( 4 ) C ou n t y / l o c a l C a n d i d a t e( S ) C o u n t y PAC ( e ) e a l o t I s s u e ( i = r a n c n i s e Co mmi t t e e ( 7 ) C a u n t y j C i l y Ce n t r a l C o mmi t t e e( e ) S u p po r t S t a t e o f Ca n di d a t e s

( Z I A ) - 3 . 1 3TELEPHONE

o Ch e c t c N t h i s i s f i n a l ( t e r mi 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

CASHON 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 mo n i e s h e l d

b y t h e c o mmi t t e e . T h i s amou n t MUST b e t h e sa me a s t h e c as 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 mu st 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

ADD TOTAL MONEY TAKEN I N T HI S PERI OD

Sc h e d u l e A Cash C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e d u l e A ) ( ' a l s o s e e i n - k i n d b e l o w ) . . . . . . .Sc h e d u l e F : L o a n s Re c e i v e d t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d u l e H : T o t a l Sa l e s o f Camp a i g n P r o p e r t y ( A t t a c h Sc h e d u l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( S c he d u l e H a p p l i e s I l o Ca n d i d a t a s ' C o mr n i t t e 9 l l i On l y )

SUB- TOTAL . . . . . $

SUBTRACT TOTAL MONEY SPENT T HI S PERI OD

Sc h e d u l e & E x p e n d i t u r e s t o t a l ( A t t a c h Sc h e d u l e B ) ( " a l s o s e e d eb t s a n d l o a n s b e l o w ) . .Sc h e d u l e F : L o a n Re p a y me n t s t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CASHON HAND a t t h e e n d o f t h i s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t , b a l a n c e mu st

b e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

" UNPAI DBI L L S ( Fr o m Sc h e d u l e D - A t t a c h Sc h e d u l e D ) , . . . . , . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . $' I N KI ND CONTRI BUTI ONS ( F r o m Sc h e du l e E- At t a c h Sc h e d u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $* * OUTSTANDI NG LOANS ( F r o m Sc h e d u l e F - A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

CANDI DATE COWI TTEES ONLY :

CONSULTANT 13REAKDOWN ( Sc h e d u l e G A t t a c h e d? )

VALUE OF CAMPAI GN PROPERTY ( F r o m Sc h e d u l e H - A t t a c h Sc h e d u l e H)

L a t e f i l e d r e p o r t s a r e s u b j e c t t o p os s i b l e c i v i l a n d c r i m i n a l p e n a l t i e s .

SE E I NSTRUCTI ONS ONBACKANDCOMPL ET E THE FOL L OWI NG SENTENCE

I AM HUNGA REPORT FORANI A ( 1 ) E L ECT I ON I ( 2 ) NON- E L ECT I ON YEAR.( r e p o r t d a t e ) / , 1 - , V - 6 ' 3 PC, I n d i c a t e o n e

P~KECK I F AMENDMENT TO REPORT DATED ( - 011 L o r a l C o mmi t t e e s , e n t e r Da 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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J nN 2 1 2003 8 : 3 0n N HP LRSERJ ET 3200

FOR I NSTRUCTI ONS, SEE BACK OF FORM

DI SCLOSURE SUMMARY PAGERe se t Fo r m

COMMI TTEE NAME ( Mu s t b e sa me o n St a a n t o f O r g a n i z a t i o n )

C t i~. ~~t J + s rg&Rf11qf iII MPORTANT : I n d i e a t s t y p e o f c o mmi t t e e y o u a r c r e p o r t i n g f o r

( 1 ) S t a t e w i d e k e g i s t a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PA C ( 3 ) S l a t e P a r t y ( 4 ) C o u n l y l L o c a l C a n d i d a t e( 5 ) C o u n t y PA C ( s ) B a l l o t i e s u e / F r a n c h i s a C o mmi t t e e ( 7 ) C o u n t y l C i t y C e n t r a l C o mmi t t e e( 8 ) p or t S l a t e o f C a n d i d a t e s

CANDI DATE COMMI TTEES ONLY:

Ca nd i d a t e Name P o l i t i c a l P a r t y

. S f e y a t l U s : " 4 ( i i o i i kM*rJ D emO f f i c e Soug h t D i s t r i c t ( i f Se n a t e o r House)

1 4- 0 r , x le & 9 t ~ C- P l

FORM

DR- 2 I DI SCLOSURE

( Re v . 0 1 1 2 0 0 3 ) REPORT

F o r O f f i l s Us e O t t h r

c omm . s I : 3 3- T'I n d e x e d

A u d i t e d

Compu t e r

SI GNATURE OF T URER ( o r p e r s o n f i l i n g t h i s r e p o r t )

L a t e f i l e d r e p o r t s a r e s ubj e c t t o p o s s i b l e c i v i l and c r i mi na l p ena l t i e s .

SEE I NSTRUCTI ONS ON BACK ANDCOMPLETE THE FOLLOWI NGSENTENCE :

I AM F I L I N G A ( - - a t " O1E PT FORANI A ( 1 ) ELECTI ON 1( 2 ) NON- ELECTI ON YEAR .( r e p o r t d a t e ) I n d i c a t e onea

HECK I F AMENDMENT TO REPORT DATED r - A ' " ' 6 ) A

Che 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 nd 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 or m DR- 3 .( Yo u mu s t c o n t i n u e t o i t s 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 OFCASHONHAND

TEL EPHONE DATE SI GNED

CASH ONHAND 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 db y t h e c o mmi t t e e T h i s amount MUST b e t h e s a m e a s t h e c a s h o n h a n d a t t h e end

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 mus t 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

L o c a l C o n x t t i t f 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 3 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 i i e r i i s h e l d

F .

ADD TOTAL MONEY TAKEN I N T HI S PERI OD

Sc h e d u l e A : Cash C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e d u l e A) ( * a l s o s ee i n - k i n d b e l o w ) . . . . . . . . . .Sc h e d u l e F : L o a n s Re c ei v e d t o t a l ( A t t a c h Sc h e d ul e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d u l e H : T o t a l S a l e s o f Ca mp a i g n P r o p e r t y ( A t t a c h Sc h e d ul e H ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( Sc h e d ul e H a s I l e a b C a l l d i d a t e s ' Co mmi ! l e oa On t y l

SUB- TOTAL . . . . . $

SUBTRACT TOTAL MONEY SPENT THI S PERI OD

Sc h e d u l e B : E x p e n d i t u r e s t o t a l ( A t t a c h Sc h e d ul e B ) ( " a l s o s e e d e b t s a nd l o a n s b e l o w ) . . . I 1

Sc h e d u l e F . L oan Re p a y me n t s t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CASH ON HAND a t t h e end o f t h i s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t , b a l a n c e mus t

t ~b e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

13T, 4 d _

_

* * UNPA I D BI L L S ( F r o m Sc h e d ul e D - A t t a c h Sc h e d ul e D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . $

* I N K I ND CONTRI BUT10NS ( F r o m Sc h e d ul e E - A t t a c h Sc h e d ul e I F ) _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

* * OUTSTAND I NG LOANS ( F r o m Sc h e d u l e F - A t t a c h Sc h e d ul e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

CANDI DATE COMMI TTEES ONLY:

CONSULTANT BREAKDOWN ( S c h e d u l e G A t t a c h e d ? ) DYESaNO

VALUE OF CAMPAI GN PROPERTY ( Fr om Sc h e d u l e H - A t t a c h Sc h e d ul e H ) $



FORl i : l S. TRUCTI ONS, SEEBACKOFF 4

DI SCLOSURE SUMMARY PAGE

COMMI TTE NAME ( Mu s t be

G~ - - ~ t a~NS

e a s on. . St a t e me nt o f Or g a ni z a t i on)

Alm

I MPORTANT: I n d i c a t e t y p e o f c o mm i t t e e y o u a r e r e p o r t i n g f o r :

( t ) 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 / F r a n c h i s e C o mmi t t e e ( 7 ) Co u p i t y C e n t r a l C o mm i t t e e( 8 ) Su p po r t S l a t e o f Ca nd i t e s

SI GNATURE OF TREASURER ( o r p er s o n f i l i n g t h i s r e p

R o 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 R e p o r t s Range f r o m $ 2 0 t o $ 8 0 0

SEE I NSTRUCTI ONS ON BACKANDCOMPLETE THE FOLLOWI NG SENTENCE :

I AM F I L I NG A I ~2, , 2 ~NUZ REPORT FOR ANNA ( 1 ) ELECTI ON / ( 2 ) N ON - EL ECTI ON YEAR .

I nd 4t e one a]( r e p o r t d a t e )

OCHECK I F AMENDMENT TO REPORT DATED

E l Chec 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 nd 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 or m DR- 3 .

( Y o u mus t 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 es ame a s t h e c as h o n h a n d a t t h e end 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 mus t 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

Sc h ed u l e A: Cash C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e du l e A ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sc h ed u l e F : Loan s Re c ei v e d t o t a l ( A t t a c h Sc h ed u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sc h ed u l e H: T o t a l Sa l e s o f Ca mp a i g n P r o p e r t y ( A t t a c h Sc h ed u l e H ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( Sc h ed u l e H a p p l i e s t o Ca n di d a t e s ' Commi t t e e s On l y )

SUB- TOTAL . . . . . . $

SUBTRACT TOTAL MONEY SPENT THI S PERI OD

Sc h ed u l e B : E x p e n d i t u r e s t o t a l ( A t t a c h Sc h ed u l e B ) . . . . . . . . . . . . . . . . . . . ` ~. . . . . . . . . . . . . . . . .

Sc h ed u l e F : L o a n Re p a yme n t s t o t a l ( A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CASH ON HAND a t t h e end o f t h i s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t , b a l a n c e must

b e z e r o ) ( A t t a c h DR- 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . ~ ` ~. . . , . , . . . . . $

UNPAI D BI L L S ( F r om Sc h ed u l e D - A t t a c h Sc h ed u l e D ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

DI SCLOSURE

REPORT

Comm . #

I n d e x e d

A u d i t e d o ' 1 ' a 5 0 , 3Compu t e r ( I - - + i A) I Z

7 / . - - 2 0n -. . a r / s - : ) 9 / - v z - ~Z

TELEPHONE DATE S I G NED

L o c a l C o mmi 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 mmi 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

1 , 0 0% e / ( o,

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QkI N K I ND CONTR I BUT I ONS ( F r om Sc h ed u l e E - A t t a c h Sc h ed u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

OUTSTANDI NGLOANS ( F r o m Sc h ed u l e F - A t t a c h Sc h ed u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

CANDI DATE COMMI TTEES ONLY-

CONSULTANT BREAKDOWN ( S c h e d u l e GA t t a c h e d ? ) - YES_ NO

VALUE OF CAMPAI GN PROPERTY ( F r o m Sc h ed u l e H - A t t a c h Sc h ed u l e H )



Fo r I n s t r u c t i o n s , See Back 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 St a t e me n t o f Or g a n i z a t i o n)

Gi ' f l ? N. S A- - o f & GrDLam41y

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 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: S e 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 o p i ed f r o m r e p o r t s a n 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 n y c o mmer c i a l p u r p o se by a n y p er 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 .

TOTAL ( i f l a s t page o f t h i s

s c h e du l e )

' 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 mm i 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 mm i t t e e . R e l a t i o n s h i p mu s t b e s h own 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 yma r r i a g e ) ( S e e Pa g e 2 o f f o r m s p 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 ame a s c a n d i d a t e , b u t t h e r e i s n of a mi 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 .

SUB- TOTAL

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http://slidepdf.com/reader/full/gorman-steven1331scanned 5/6( f o r S c he d u l e B )

FOR I NSTRUCTI ONS, SEE BACK OF 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 BUT I ONS MADE TO STATEWI DE OR LEGI SLAT I VECANDI DATES, L I ST THE CANDI DATE I DENT I F I CATI ON NUMBER I N THE DESI GNATED COLUMN AND THE 0 1 CHECK T HI S BOX I F

PAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVA I LABLE FROM THE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD.

COMMI TTEE NAME ( Mu s t b e s ame a s on St a t eme n t o f Or g an i z a t i o n)

CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNT

DATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

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T HI S BOX APPL I ES TO CANDI DATES' COMMI TTEES ONLY :

Pu r c h a s e s o f c e r t a i n c a mp a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r mo r e mu s t a l s o be i n v e n t o r i e d on Sc h e d ul e H . ( R e f e r t o Sc h e d ul e H i n s t r u c t i o n s . )

E x p e n d i t u r e s t o p e r s o n s / e n t i f e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , manag i n g , o r g a n i z i n g s e r v i c e s mus t a l s o be d e t a i l i t e m i z e d onSc h e d ul e G by t h e a mo u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e made b y t h e p e r s o n / e n t i t y on b e h a l f o f t h e c a n d i d a t e ' s c o mmi t t e e . ( R e f e r t o

Sc h e d ul e G i n s t r u c t i o n s an d I o wa Code 5 6 . 6 ( 3 ) ( i ) . )



T H I S BOX A PP L I E S TO CAND I DATES ' COMMI TTEE S ONL Y :

P u r c h a s e s o f c e r t a i n c a m p a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r mo r e m u s t a l s o b e i n v e n t o r i e d o n S c h e d u l e H . ( R e f e r t o S c h e d u l e H i n s t r u c t i o n s . )

E x p e n d i t u r e s t o p e r s o n s / e n t i t i e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , o r g a n i z i n g s e r v i c e s m u s t a l s o b e d e t a i l i t e mi z e d o nS c h e d u l e G b y t h e a mo u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e made b y t h e p e r s o n / e n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o mmi t t e e . ( R e f e r t

S c h e d u l e G i n s t r u c t i o n s a n d I o w a C o de 5 6 . 6 ( 3 ) ( 1 ) . )

( f o r S c h e d u l e B )

FORI N S TRUCT I ONS , SEEBACK OF FORM SCHEDULE

EXPEND I TURES B MONETARY- - MONEY S P EN T FROM COMMI TTE E ACCOUNT

( R e v . 0 9 1 9 7 ) EXPEND I TURES

STATE P A C COMMI TTEE S : NOTE : FOR CONTRI BUTI ONS MADE TOSTATEWI DE OR L E G I S L A T I V EOCHECK THI S BOX I FCANDI DATES , L I S T THE CAND I DATE I D E N T I F I C A T I ON NUMBER I N THE DES I GNATED COL UMN AND THE

PAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS 1 S A V AI L ABLE FROM THE I OWA AMENDI NG FORMET HI CS & CAMPA I GN DI SCL OSURE BOARD .

COMMI TTE E NAME ( M u s t b e same 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 )

' 0G'CAND I D ATE NAME AND A D DRE S S TOWHOM PURPOSE AMOUNT

DATE I D NUMBER EXPENDI TURE ( D ES CRI BE TRANSACT I ON ) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e me n t ) WAS MADE( MM/ DD/ YR) AND P A C

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