ibew_2005_linn_otc

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  • 8/7/2019 IBEW_2005_Linn_OTC

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    COMMI TT EE NAMEO f f i c i a l Name o f O u t - o f - S t a t e C o mm i t t e e ( D o n o t a b b r e v i a t e c o mm i t t e e n ame . W r i t t e n e x p l a n a t i o n mu s t b e p r o v i d e d f o r A c r o n y m ) .I n t e r n a t i o n a l B r o t h e r h o o d o f E l e c t r i c a l Wo r k e r s ( I BEW) PAC -

    1 1 2 5 1 5 t h S t . , N. W. M a i l i n g A d d r e s sWa s h i n g t o n , DCC~ %I j b ? t e ' Z i p C o d e C o d e 7 2 8 - 6 a 1 p h o n e No .

    STATEOR FEDERAL J URI SD I CT I ON WHERE COMMI TT EEI S REGI STERED OR OPERATES

    F e d e r a l E l e c t i o n Co r n mi s sameo f J u r i s d i c t i o n9 9 9 E. S t r e e t , N. W. M a i l i n g A d d r e s s

    l %M%A, X20463 T e l e ) 6 9 4 - 1 1 3 7_ I BEW1 1 2 5 1 5 t h S t . , N. W .

    NameM a i l i n g A d d r e s s

    Wa s h i n g t o n , DC 2 0 0 0 5 " ' S t a t e , Z i p C o d e

    PURPOSEOF COMMI TT EE

    N o n - p a r t i s a n P o l i t i c a l L e a g u e

    I OWA RESI DENT AGENT

    I OWA ETHI CS AND CAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SU I TE 1 A1 6 T , DES MOI NES, I A 5 0 3 1 9www. l o w a . g o v / e t h i c sVERI F I ED STATEMENT REGI STRATI ON( O u t - o f - S t a t e Co ml ml t t e e )

    COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPL ETE I N DUPL I CATE.SEND A COPY TO THE BOARD WI T H I N 1 5 DAYS OF THE CONTRI BUTI ON DATE ANDONE COPY WI TH EACH CONTRI BUTI ON TO THE I OWA COMMI TTEE WI TH THE CONTRI BUTI ON .PLEASE REFER TO D ET A I L E D I NSTRUCTI ONS ON BACK OF FORM .T H I S FORMMUST BE F I L ED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0

    T y p e d Name o f I o w a R e s i d e n tSandy Op s t v e d t - - _-

    M a i l i n g A d d r e s s1 4 3 5 N . E . 5 4 t h ~v e .

    C i t y , S t a t e , Z i p C o d e T e l e p h o n eDe s Mo i n e s , I A 5 0 3 1 3 ~. ~ ( 5 1 5 ) 2 6 5 - 6 1 9 4

    ED STATEMENT Ot C MMI TTEE :% Vi l l

    ( P e r s o n s u b m i t t i n g f o r m )

    PARENT ENTI TY, A FF I L I A TE , SPONSOR OF COMMI TT EE( U s e s e p a r a t e p a g e i f n e e d e d t o l i s t m o r e t h a n o n e e n t i t y )

    I OWA COMMI TTEE RECEI V I NG CONTRI BUTI ON

    3 2 0 1 P e b b l e D r i v e Sw, Ceda r R a p i d s I A 5 2 4 0 40 8 / 1 5 / 2 0 0 5

    n u n t$ 5 , 0 0 0 . 0 0

    Se c r e t a r y - T r e a s u r e r( T i t l e )

    Name o f C o mm i t t e eS h i e l d s f o r Ceda r Ra p i d sM a l l i n a A d d r e s s

    C h e c k #8 9 3 1

    ~ l n r i JF o r m V E R I F I E D STATEMENTREGI STRATI ON( O u t - o f - - S t a t e C o mmi t t e e s )( R e v . 0 7 / 0 3 )F o f f i c e n lComm. # __I n d e x e dA u d i t e dC h e c k e d --C o mp u t e r

    C o n t r i b u t i o n

    ( D a t e )

    ~ t t h e c o n t r i b u t i o n r e p o r t e d a b o v e I s a c c u r a t e a n d t h a t t h e i n f o r m a t i o n a b o u t t h i s o u t - o f - s t a t e- e e I s c o r r e c t a n d a c c u r a t e t o t h e b a s o f my k n o wl e d g e . 1 a l s o a t t e s t t h a t t h e r e p o r t s f i l e d i n t h e na med j u r i s d i c t i o n c o mp l y w i t h r e q u i r e m e n t s t h a t a r e_ .s u b s t a n t i a l l y s i m i l a r t o I o wa Co d e s e c t i o n 6 6 A. 6 , I n c l u d i n g t h e d i s c l o s u r e o f a l l c o n t r i b u t i o n s r e c e i v e d a n d a l l e x p e n d i t u r e s ma d e . I f u r t h e r a t t e s t t h a t t h ec o n t r i b u t i o n r e p o r t e d a b o v e wa s ma d e f r o m a n a c c o u n t t h a t d o e s n o t a c c ep t c o n t r i b u t i o n s f r o m c o r p o r a t i o n s o r o t h e r p r o h i b i t e d c o n t r i b u t o r s u n d e r I o wa Co d es e c t i o n 6 8 , f . 1 5 , u n l e s s t h e I o w a r e c i o o mmi t t e s i s a b a l l o t i s s u e c o mmi t t e e . 1 u n d e r s t a n d t h a t p o t e n t i a l 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 may a p p l y u n l e s s a c o p y o ft h i s f o r m Me b e e n f i l e d t h t h a l o E a c s a n d C mp s i o n D i s c l o s u r e Bo a r d w i t h i n 1 5 d ay s o f t h e d a t e o f t h e c o n t r i b u t i o n . 0 8 / 1 5 / 2 0 0 5