ibew_pac_8026_linn_county

8/7/2019 IBEW_PAC_8026_Linn_County

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COMMI TTEES NOT ORGANI ZED I N I OWA TOCOMPLETE I N DUPL I CATE .SEND A COPY TO THE BOARD WI T HI 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 DETAI LED I NSTRUCTI ONS ON BACK OF FORM .THI S FORM MUST BE F I L EDFOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0COMMI TTEE NAME

O f f i c i a l Name o f O u t - o f - S t a t e Co mmi t t e e ( Do n o t a b b r e v i a t e c o mm i t t e e name . Wr i t t e n e x p l a n a t i o n mus 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 Br o t h er h o od o f E l e c t r i c a l Wo r k e r s ( I BEW) -9 0 0 Se v e nt h S t r e e t , NWWa s h i n g t o n , DC C~ 6 0 b y t e , Z i p Code

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PURPOSE OF COMMI TTEE

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M a i l i n g A dd r e s sC i t y , S t a t e , Z i p Code T e l e p h o n eDes Mo i n e s , I A 5( 1 5 ) 2 6 5 - 6 1 9 4

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c o n t r i b u t i o n p o r t e d a b o v e was mes e c t i o n 6 8 4 1 5 , u n l e s s t h q I o wa r e c tt h i s f o r sMf i l e d t hc J .( P e r s o n s u b mi t t i n g f o r m )

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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 ma t i o n a b o u t t h i s o u t - o f - s t a t ec t an d a c c u r a t & - t 6 t h e - b e s t o f ~y k n owl ec t o 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 omp l y w i t h r e q u i r e me n t s t h a t a r es u b s t a n t i a l l y s i m i l a r t o I o wa Code s e c t i o n 6 8A. 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 an d a l l e x p e n d i t u r e s made . I f u r t h e r a t t e s t t h a t t h eman a c c o u n t t h a t d o e s n o t a c c e p 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 Codeo mmi t t e i s a b a l l o t i s s u e c ommi t t e e . I u n d er s t a nd t h a t p o t e n t i a l c i v i l a n d c r i mi n a l p e n a l t i e s may a pp l y u n l e s s a c o p y o fr g n ' J ' g n Di s u r e B o ar d w i t h i n 1 5 d a y 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 .S e c r e t a r y - T r e a s u r e r 1 1 / 1 7 / 2 0 0 5

( T i t l e ) ( D a t e )

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I OWA COMMI TTEE RECEI VI NG CONTRI BUTI ON


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I OWA ETHI CS ANDCAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1ADES MOI NES, I A 5 0 3 1 9www. l o wa . g o v / e t h i c sVERI F I ED STATEMENT REGI STRAT I ON? o o t ( O u t - o f - S t a t e Co mmi t t e e )

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STATE OR FEDERAL J URI SDI CT I ON WHERE COMMI TT EEI S REGI STERED OR OPERATES

PURPOSEOF COMMI TT EE

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O f f i c i a l Name o f Ou t - o f - S t a t e Commi t t e e ( Do n o t a b b r e v i a t e c o mm i t t e e name . Wr i t t e n e x p l a n a t i o n must 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 Br 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)9 0 0 Se v e n t h S t r e e t , NWWa s h i n g t o n , DC CMObT t e , Z i p Co de

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l J o n F . We l t e r s a t t e s t t h a 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 ec o mmi t t 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 es t o f my k n o wl e d g e. l 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 me n t s t h a t a r es u b s t a n t i a l l y s i mi l a r t o I o wa Co d e s e c t i o n 6 8 A. 5 , 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 m a 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 m a n a c c o u n t t h a t d o e s n o t a c c e p 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 l i B A . 5 , u n l e s s t h e I o wa r e c i p l e nt ~mmi t t e e 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 er 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 pp l y u n l e s s a c o p y o fht bt h i s f o r ma e e n r i l e d w i t h t h e l o w a l E t h i c s a nd C 1 ~ r p i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .1 0/ 2 8/ 2 00 5


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COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPLI CATE .SEND A COPY TO THE BOARD WI THI N 1 5 DAYS OF THE CONTRI BUTI ON DATE ANDONE COPY WI TH EACH CONTRI BUTI ON TO THE I OWA COMMI TT EE WI TH THE CONTRI BUTI ON .PLEASE REFER TO DETAI LED I NSTRUCTI ONS ON BACK OF FORM.THI S FORM MUST BE F I L ED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0COMMI TTEE NAME

O f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( D o n o t a b b r e v i a t e c o mmi t t e e name . Wr i t t e n e x p l a n a t i o n mus t b e p r o v i d e d f o r Ac r o n y m) .I n t e r n a t i o n a l Br o t h er h o o d o f E l e c t r i c a l Wo r k e r s ( I B EW)9 0 0 Se v e n t h S t r e e t , NWWa s h i n g t o n , DC CMTt e, Z i p Code

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t h e b es t o f my k n o wl e d ge . 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 r i l e d i n t h e named j u r i s d i c t i o n c omp l y w i t h r e qu i r e me nt s t h a t a r es e c t i o n 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 ec e i v e d a n d a l l e x pe n d i t u r e s made . I f u r t h e r a t t e s t t h a t t h e' ' i t &ee%ccoun a t d o e s n o t a c c e p 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 Codeloo t i s s ue c o mmi t t e e. I u n de r s t a nd 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 ma y a pp l y u n l e s s a c o p y o fs c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .

( T i t l e ) ( D a t e )


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COMMI TTEE NAME

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I J o n F . Wa l t e r s , a t t e s t t h a 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 ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t e e i s c o r r e c t an d a c c u r a t e t o t h e b e s t 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 omp l y w i t h r e q u i r e me n t s t h a t a r es u b s t a n t i a l l y s i mi l a r t o I o wa Code s e c t i o n 6 8 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 made . 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 r t e d a b o v e was made an a c c o u n t t h a t d o e s n o t a c c e p 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 nd er I o wa Codes e c t i o n 6 8 A. 1 5 u n l e s s t h e I o wa r e c i p i e c o mi t t e e i s a b a l l o t i s s u e c o mmi t t e e. I u n d er 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 mi 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 h as f j ~ g _ f i l e d wi t ~ he l o " F , J i s anan CWmf p i g p D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .t

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COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPLI CATE .SEND A COPY TO THE BOARDWI THI 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 DETAI LED I NSTRUCTI ONS ON BACK OF FORM .THI S FORM MUST BE F I LED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0

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PURPOSE OF COMMI TT EE


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M a i l i n g A d d r e s s3 2 0 1 P e b b l e D r i v e SW, C e d a r R a p i d s , I A 5 2 4 0 4Da t e1 0 / 2 4 / 2 0 0 5Amo un t$ 5 0 0 . 0 0

I f I n - K i n d C o n t r i b u t i o n , D e s c r i b eC o n t r i b u t i o nCheck # Co mmi t t e e . I D #1 1 7 1 7 1 8 0 2 6

VERI F I ED STATEMENT OF COMMI TT EE :I J on F. Wa l t e r s , a t t e s t t h a 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 ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t 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 e s t o f my k n o w l 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 named 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 es u b s t a n t i a l l y s i m i l a r t o I o w a Code s e c t i o n 6 8 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 and a l l e x p e n d i t u r e s made . / 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 made 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 e p 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 hi b i t ed c o n t r i b u t o r s u n d e r I o w a Codes e c t i o n 6 8 A . 1 5 , u n l e s s t h e I o w a r e c i p i e n t c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e . I 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 nd c r i mi 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 h a s b e en r i l e d w i t h t h e I o w a P h i q s a n d Ca mp a i g n D i s c l o s u r e B o a r d w i t h i n 1 5 d a y 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 .

I OWA ETHI CS AND CAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2t h , SUI TE 1ADES MOI NES, I A 50319www. i o wa . 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 Commi t t e e)

Wr i t t e n e x p l a n a t i o n mus t b e p r o v i d e d f o r A c r o n y m) .

,~mCode 7 2 8 - 6 T e p h o n e No .

PARENT ENTI TY , AFFI L I ATE, SPONSOR OF COMMI TT EE( Us e s e p a r a t e p a g e i f needed t o l i s t mo r e t h a n o ne e n t i t y )I BEW Name9 0 0 S e v e n t h S t r e e t , NWa i i n g A d d r e s sWa s h i n g t o n , DC 2 0 0 8 i t y , S t a t e , Z i p Co de

Fo r m VERI F I ED STATEMENTREGI STRATI ON( O u t - o f - S t a t e C o mmi t t e e s )( Re v . 0 7 / 0 3 )Fo r o f f i c e u s e o n l yComm . #I n d e x e dA u d i t e dC h e c k e dCompu t e r


e c r e t a r y - T r e a s u r e r 1 0 / 2 4 / 2 0 0 5( T i t l e ) ( D a t e )


8/30

COMMI TTEES NOT ORGANI ZED I N I OWA TOCOMPLETE I N DUPLI CATE .SEND A COPY TO THE BOARD WI THI 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 DETAI LED I NSTRUCTI ONS ON BACK OF FORM .THI S FORM MUST BE F I L ED FOREACH CONTRI BUTI ON I N EXCESS OF $ 5 0

COMMI TTEE NAME

I CS AND CAMPAI GN DI SCL OSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1ADES MOI NES, I A 5 0 3 1 9www. l o wa . g o v / e t h i c s

VERIFIEDSTATEMENTREGISTRATION( O u t - o f - S t a t e Co mmi t t e e )

O f f i c i a l Na me o f O u t - o f - S t a t e Co mmi t t e e ( Do n o t a b b r e v i a t e c o mmi t t e e n am e .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)9 0 0 Se v e n t h S t r e e t , NW M a i l i n g A d dr e s sWa s h i n g t o n , DC Ck o b y t e , Z i p Code

STATE OR FEDERAL J URI SDI CT I ON WHERE COMMI TTEEI S REGI STERED OROPERATES

j n F

F . E . C . Name o f J u r i s d i c t i o n I I I 1BEW9 9 9 E S t r e e t , NW

a s P g ^ t ~ 1 4 , ` 1 5 & 2 0 4 6 3


No n- Pa 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 AGENTS a n d y Op s t v e d t

1 4 3 5 N. E . 5 4t h A v e n u e


M a i l i n g Ad d r e s s

C i t y , S t a t e , Z i p Code Te l e p h o neDe s Mo i n e s , I A 2 6 5- 6 1 94

M a i l i n g A d d r e s sT e l e Te ) 6 9 4- 1 1 3 7

Wr 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) .

/ ~ Cod ) 7 2 8 - 6 0T f 6 p h o n e No .

PARENT ENTI TY, AFFI L I ATE, SPONSOR OF COMMI TTEE( 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 mo r e t h a n o n e e n t i t y )Name

9 0 0 Se v e n t h S t r e e t , NWMa i l i n g A d d r e s sWa s h i n g t o n , DC 2 0 0Rt y , S t a t e , Z i p Code

I OWA COMMI TTEE RECEI V I NG CONTRI BUTI ONNa me o f Co mmi t t e e

Sh i e l d s f o r C e d a r Ra p i d sM a i l i n g A d d r e s s

3 2 0 1 Pe b b l e Dr i v e SW, C e d a r Ra p i d s , I A 5 2 4 0 4D a t e9 / 3 0 / 2 00 5Amoun t$ 2 5 0 . 0 0

I f I n - K i n d C o n t r i b u t i o n , D e s c r i b eCo nt r i b ut i o n

Fo r m VERI F I ED 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 r o f f i c e u s e o n l yComm . #I n d e x e dA u d i t e dCh e c k e dComp u t e r

Ch e c k # Co mmi t t e e . I D #9 0 5 1 18026

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 ma t i o n a b o u t t h i s o u t - o f - s t a t ec omm' " ' c o e t a n d a c c u r a t e t o - T h e b e s t o f my k n o wl e d g e: - 4 a l s o a t t e s t t h a t t h e r e p o r t s r 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 es 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 8 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 m a 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 was m a d e f r o m a n a c c o u n t t h a t d o e s n ot a c c e p 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 A . 1 5 , u n l e s s t h e I o wa r e c i p i e n t co m i s a b a l l o t i s s u e c o mmi t t e e . 1 u nd 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 mi n a l p e n a l t i e s ma y 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 h a s b e e n f i l q # w i t h t h e I o wa E t h i c s a t * C mp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .

Oa p u ! r e a s u r e r 9/ 30 / 2 0 05"J ( T i t l e ) ( D a t e )


9/30

COMMI TTEE NAMEO f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( Do n o t a b b r e v i a t e c o mm i t t e e name .I n t e r n a t i o n a l Br o t h er h o o d o f E l e c t r i c a l Wo r k e r s ( I B EW)-

9 00 S ev e n t h S t r e e t , NW M a i l i n g A d dr e s sWa s h i n g t o n , DC ( : A Ob Tt e , Z i p Code

STATE OR FEDERAL JUR I SDI CT I ON WHERE COMMI TTEEI S REGI STERED OR OPERATES



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 ma t i o n a b o u t t h i s o u t - o f - s t a t er r e c t a n d a c c u r & e1 o t h l r b e s t b f l n y T c n o w l f e I a l s o a t t e s t t h a t t h e r e p o r t s r i l e d i n t h e na med j u r i s d i c t i o n c omp l y w i t h r e q u i r e m e n t s t h a t a r es 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 de s e c t i o n 6 8 A . 6 , i n c l u d i n g " F 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 en d i t u r e s made . 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 mad e f r o m a n a c c o u n t t h a t d o e s n ot a c c e p 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 de r I o w a Co des e c t i o n 6 1 5 , u n l e s s t h e I o wa r e i e t c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e. I u n d er s t a nd t h a t p o t e n t i a l c i v i l and c r i mi n a l p e n a l t i e s may a pp l y u n l e s s a c o p y o ft h i s f o r m s b e e n f i l e i t h t h t o a i c s a n d Campa i g n D i s c l o s u r e B o ar d w i t h i n 1 5 d a y 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 .

F . E . C.999 E S t r e e t , NW

Name o f J u r i s d i c t i o nM a i l i n g A d d r e s s

a SWWt &, ~5& 2 0 4 6 3 Te l e " a , 6 94 - 1 13 7

NameI BEW900 S ev e n t h S t r e e t , NWMa i l i n g A d d r e s sWa s h i n g t o n , DC 2 0 0 8 f t y , S t a t e , Z i p Code

S a n d y Op s t v e d t

1 4 3 5 N. E . 5 4t h A v e n u eC i t y , S t a t e , Z i p Code T e l e p h o n eDe s Mo i n e s , I A

I OWA ETHI CS ANDCAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1 ADES MOI NES, I A 5 0 3 1 9www. i o w a . g o v / e t h i c s7MERI F I ED STATEMENT REGI STRATI ON

No n - P ar t i s an P o l i t i c a l L e a g u e

( O u t - o f - S t a t e Commi t t e e )COMMI TT EES NOT ORGANI ZED I N I OWA TO COMPL ETE I N DUPL I CATE .

SENDA COPY TO THE BOARDWI THI N 1 5 DAYS OF THE CONTRI BUTI ON DATE ANDONE COPY WI TH EACH CONTRI BUTI ON TOTHE I OWA COMMI TTEE WI TH THE CONTRI BUTI ON .PLEASE REFERTODETAI LED I NSTRUCTI ONS ON BACK OF FORM.T HI S FORMMUST BE F I LED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0

T y pe d Name o f I o w a R e s i d e n t


5( 1 5 ) 2 6 5 - 6 1 94

Name o f Co mmi t t e eS h i e l d s f o r Ceda r Ra p i d s

M a i l i n g A dd r e s s3 2 0 1 P eb b l e Dr i v e SW, Cedar Ra p i d s , I A 5 2 4 0 4

Da t e

PARENT ENTI TY, AFF I L I ATE, SPONSOROF COMMI TTEE( U s e s e p a r a t e p a g e i f nee de d t o l i s t mo 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

0 8/ 2 9/ 2 00 5Amou n t$ 5 00 . 0 0

Code T h o n e No .- L 7 2 8 - 6 0 X~ p - .

Fo r m VER I F I ED 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 r o f f i c e u s e o n l yComm. #I n d e x e dA u d i t e dChe cke dCompu t e r

Wr i t t e n e x p l a n a t i o n mus t b e p r o v i d e d f o r Ac r o n y m) .

I f I n - K i n d C o n t r i b u t i o n , D e s c r i b eCo n t r i b u t i o n sCheck #8 9 90

Commi t t e e . I D #8 0 2 6

e t a r y = T r e a s u r e r - 8 - 2 9- 2 00 5( P e r s o n s u b mi t t i n g f o r m ) ' ' ~ ( T i t l e ) ( D a t e )


10/30


11/30


12/30

COMMI TTEE NAME

I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1 ADES MOI NES, I A 5 0 3 1 9www . i o w a . g o v / e t h i c s~ RI FI ED STATEMENTREGI STRATION( O u t - o f - S t a t e Co mmi t t e e )

COMNTTt ES NOT ORGANI ZED I N I OWA TO COMPL ETE I N DUPL I CATE .SEND A COPY TO TH E BOARD WI THI N 1 5 DAYS OF T HE CONTRI BUTI ON DATE ANDONE COPY WI TH EACH CONTRI BUT I ON T O T HE I OWA COMMI TTEE WI TH T HE CONTRI BUT I ONPLEASE REFERTO DETA I LED I NSTRUCT I ONS ON BACK OF FORM.T HI S FORM MUST BE F I L ED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0

O f f i c i a l Name o f O u t - o f - S t a t e C o mmi t t e e ( D o n o t a b b r e v i a t e c o mmi t t e e name . Wr 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 Br 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 BENV ) -9 0 0 Se v e n t h S t r e e t , NW M a i l i n g A d d r e s sWa s h i n g t o n , DC C ~O 0 b t p t e , Z i p Co de


F . E . C .9 9 9 E S t r e e t , NW

QX y a S 4 f t g j p , boe 2 0 4 6 3

Name o f J u r i s d i c t i o nM a i l i n g A d d r e s s

T e l e p( e 1 6 9 4 - 1 1 3 7


No n - Pa r t i s an P o l i t i c a l L e a g u e


Sa n d y Op s t v e d t

1 4 3 5 N. E . 5 4 t h A v e n u e

T y p e d Name o f I o w a R e s i d e n tM a i l i n g A d d r e s s

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 15 ) 2 65 - 6 1 9 4

C i t i z e n s f o r Pau l P a t eM a i l i n g A d d r e s s

6 8 0 1 Bowman L a n e , N. E . , Ce d a r Ra p i d s , I A 5 4 2 0 " L .~Da t e

3 / 8 / 0 5Amoun t$ 2 5 0 . 0 0

Name o f C o mmi t t e e

I f I n - K i n d C o n t r i b u t i o n , D e s c r i b eCo nt r i b ut i o nC h e c k #8 3 6 5 Co mmi t t e e . I D #1 3 0 8 3

STATE NT O F CPMPI TTEE :' 6 - N&_ 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 ec o m7 Rl k f 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 e s t o f my k n o wl 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 named 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 es u b s t a n t i a l l y s i mi l a r t o I o wa C o d e s e c t i o n 6 8 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 mad e . 1 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 was mad 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 e p 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 C o d es e c t i o n 6 8 A . 1 5 , u n l e s s t h e I o wa r e c i p i e n t c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e . 1 u nd e r s t a nd t h a t p o t e n t i a l c i v i l a n d c r i mi 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 h a s b e e n f i l e d w i t h t h e I o wa E t h i c s a n d Ca mp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .

_ J o n F Wa l t e r s( P e r s o n s u b mi t t i n g f o r m )

I BEW

C o d e T h o n e No .18 1 ) 7 2 8- 6 0 , f -

Name9 0 0 Se v e n t h S t r e e t , NWMa i l i n g A d d r e s sWa s h i n g t o n , DC 2 0 0 6 i t y , S t a t e , Z i p C o d e

PARENT ENT I TY, AFFI L I AT E , SPONSOR OF COMMI TTEE( 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 mo r e t h a n o n e e n t i t y )

I OWA COMMI TTEE RECE I VI NG CONTRI BUTI ON

S e c r e t a r y - T r e a s u r e r 3 / R/ 2 n 11 5( T i t l e ) ( D a t e )

Fo r m ' "VERI F I EDSTATEMENTREGI STRAT I ON( O u t - o f - S t a t e C o mmi t t e e s )( R e v . 0 7 1 0 3 )F o r o f f i c e u s e o n l yComm. #I n d e x e dA u d i t e dC h e c k e dCo mp u t e r


13/30

COMMI TTEE NAMEO f f i c i a l Name o f O u t - o f - S t a t e C ommi t t e e ( Do n o t a b b r e v i a t e c o mmi t t e e name . Wr i t t e n e x p l a n a t i o n mus 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 Br 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)

9 0 0 S ev e n t h S t r e e t , NW M a i l i n g A d d r e s sWa s h i n g t o n , DC CMyt e , Z i p C o d e

STATE OR FEDERAL J URI S DI C TI ONWHERE COMMI TTEEI S REGI STERED OR OPERATESF . E . C .9 9 9 E S t r e e t , NW

Gf t Mf f i t t t ' , ~ 5 0 ` 2 0 4 6 3


1 4 3 5 N. E . 5 4t h A v e n u e

s u b s t a n t i a l ,c o n t r i b u t is e c t i o nt h i s


I OWA RESI DENT AGENTS a n d y Op s t v e d t

C i t y , S t a t e , Z i p C o d e Te l e p h o n eDe s Mo i n e s , I A

VERI F I ED STATEMENT OF COMMI TTEE :1 J o n F . Wal t e r s a t t e s t t h a 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 an d t h a t t h e i n f o r ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t 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 e s t o f my k n o wl e d ge . I a l s o a t t e s t t h a t t h e r e p o r t s r i l e d i n t h e named 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 me n t s t h a t a r et i o n 6 8 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 an d a l l e x p en d i t u r e s made . l f u r t h e r a t t e s t t h a t t h ef 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 e p 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 er 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 C o d ee i s a b a l l o t i s s u e c o mmi t t e e . I u n d er s t a nd 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 pp l y u n l e s s a c o p y o fc l o s ur e B o ar d w i t h i n 1 5 d a y 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 .

I OWA ETHI CS AND CAMPA I GN DI S C LOSURE BOARDP < 5 1 0 EAST 1 2 t h , SUI TE 1 ADES MOI NES, I A 5 0 3 1 9www. i o w a . g o v / e t h i c sVE F I ED STATEMENT REGI STRATI ON( O u t - o f - S t a t e Commi t t e e)

COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPL I C ATE .SENDA COPY TO THE BOARDWI THI N 1 5 DAYS OF T HE CONTR I 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 DETA I LED I NSTRUCT I ONS ON BACK OF FORM .THI S FORM MUST BE F I L ED F OR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0

Name o f J u r i s d i c t i o nM a i l i n g A d dr e s s

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COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPLI CATE .SEND A COPY TO THE BOARD WI THI 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 DETAI LED I NSTRUCTI ONS ON BACK OF FORM .THI S FORM MUST BE F I LED F OREACH CONTRI BUTI ON I N EXCESSOF 5 0

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Fo r m VERI F I ED STAT EMENTREGI STRATI ON( O u t - o f - S t a t e C o mmi t t e e s )( Re v . 0 7 / 0 3 )F o r o f f i c e u s e o n l y .Co mm. #I n d e x e dA u d i t e dCh e c k e dCompu t e r

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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 ma t i o n a b o u t t h i s o u t - o f - s t a t eo r r e c r -a n d a d v O r g ( o 4 o t l f e l b e g t b f myy- k n o w l e . I 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 n am e d 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 me n t s t h a t a r es u b s t a n t i a l l y s i m i l a r t o I o wa Code s e c t i o n 6 8 A . 6 , i n c l u d i n 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 mad e 1 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 mad 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 e p 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 w a Codes e c t i o n 6 8 A . 1 5 , u n l e s s t h e I o w a r . p i a n t c o mmi t t e e 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 er 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 ma y a p p l y u n l e s s a c o p y o ft h i s f o l i f n h a s b e e n f i l e d w i t h t h t o E t h i c s a n d Ca mp a i g n D i s c l o s u r e B o a r d w i t h i n 1 5 d a y 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 .

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F . E . C . Name o f J u r i s d i c t i o n I B E W Name9 9 9 E S t r e e t , NW M a i l i n g A d d r e s s 9 0 0 Se v e n t h S t r e e t , NWMa i l i n g A dd r e s s

a s W f f i t t t r 1 P , b Ve 2 0 4 6 3 T e l e ) 6 9 4 - 1 1 3 7 Wa s h i n g t o n , DC 2 0 0 o ~ t y ' S t a t e , Z i p Code


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COMMI TTEE NAME




HI CS AND CAMPAI GN DI SCL OSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1 ADES MOI NES, I A 5 0 3 1 9www. l o w a . g o v / e t h i c sSTATEMENT REGI STRAT I ON( O u t - o f - S t a t e Co mmi t t e e)COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPL I CATE .SEND A COPY TO THE BOARD WI THI N 1 5 DAYS OF T HE CONTRI BUTI ON DATE ANDONE COPY WI TH EACH CONTRI BUTI ON TOTHE I OWA COMMI TTEE WI TH TH E CONTRI BUTI ON .PLEASE REFER TO DETA I LED I NSTRUCT I ONS ON BACK OF FORM.T HI S FORMMUST BE F I LED FOREACH CONTRI BUTI ON I N EXCESSOF 5 0

O f f i c i a l Name o f O u t - o f - S t a t e Co mmi t t e e ( Do n o t a b b r e v i a t e c o mmi t t e e n a m e . Wr i t t e n e x p l a n a t i o n mus 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 Br o t h er h o o d o f E l e c t r i c a l Wo r k e r s ( I B EW)9 0 0 S ev e n t h S t r e e t , NWWa s h i n g t o n , DC O ~ t f ' t e , Z i p Co d e

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Name o f Co mmi t t e eJ e r r y McGr a n e f o r Ce d a r Ra p i d s

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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 ec o r r e c t a n d a cc ur a t e l o t h e b e s t 6 f My k n o w l t i 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 es u b s t a n t i a l l y s i m i l a r t o I o wa C o d e s e c t i o n 68A. 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 m a d e . 1 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 m a 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 C o d es e c t i o n 6 8 A . 1 5 , u n l e s s t h e I o wa r e c i p c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e . I u n de 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 pp l y u n l e s s a c o p y o ft h i s f o r m 4 s b ee n f i l e d w i t h t h e l o w E t ' c s a n d C a mp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .

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COMMI TTEE NAME

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O f f i c i a l Na me o f O u t - o f - S t a t e C o mmi t t e e ( D o n o t a b b r e v i a t e c o mmi t t e e name . W r i t t e n e x p l a n a t i o n m u 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) -9 0 0 Se v e n t h S t r e e t , NWWa s h i n g t o n , DC Ob t e , Z i p C o d e

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VERI F I ED STATEMENT OF COMMI TTEE:1 J o n F . Wa l t e r s , a t t e s t t h a 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 ma t i o n a b o u t t h i s o u t - o f - s t a tc o mmi t t e e i s c o r r e c t an d a c c u r a t e t o t h e b e s t o f my k n o wl e d g e . t 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 rs 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 8A . 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 hc o n t r i b u t i o n r e p o r t e d a b o v e was 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 ot a c c e p 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 er 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 6A . 1 5 , u n l e s s t h e I o wa r e c i p i e n t c o ' t t e e i s a b a l l o t i s s u e c o mmi t t e e 1 u n de 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 pp l y u n l e s s a c o p y ot h i s f o r m h a s b e e n l e d w i t h t h e I o wa E t h i c s n Ca mp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .

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I OWA ETHI CS ANDCAMPAI GN DI SCLOSURE BOARD51 0 EAST 1 2t h , SUI TE 1ADES MOI NES, I A 5031 9' r Q ( 1 www. i o wa . g o v / e t h i c s

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( O u t - o f - S t a t e Co mmi t t e e )

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I C . Thomas Keege l , a t t e s t t h a 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 ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t 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 e s t o f my k n o wl e d g e . I 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 named 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 me n t s t h a t a r es 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 8 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 made . 1 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 e p 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 Codes e c JAn 6 8 A . 1 5 , ^ e s s t h e I o wa r e c i p i e n t c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e . I u n d er 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 mi 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 fs , fg o ( f i l e d w i t h t h e I o w a _ F t h i S ; a n d C4 * a i g n D i s c l o s u r e Bo a r d w i t h i n 15 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 .

I OWA COMMI TTEE RECE I V I NG CONTRI BUTI ON

Tr e a s ur e r 1 0/ 27 / 0 5( T i t l e ) ( D a t e )


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COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPLI CATESEND A COPY TO THE BOARD WI THI 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 DETAI LED I NSTRUCTI ONS ON BACK OF FORM .THI S FORM MUST BE F I LED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0

COMMI TTEE NAMEO f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( Do n o t a b b r e v i a t e c o mmi t t e e name . Wr i t t e n e x p l a n a t i o n mus t b e p r o v i d e d f o r Ac r o n y m) .I n t e r n a t i o n a l Br o t h er h o o d o f E l e c t r i c a l Wo r k e r s I BEW)

9 0 0 Se v e n t h S t r e e t , NW M a i l i n g A d d r e s sWa s h i n g t o n , DC ( : , A O b y t e , Z i p Code


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t h a 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 ma t i o n a b o u t t h i s o u t - o f - s t a t em i t t e e " i s c o r r e c t an d a c f r a t e t o t h e b l e s t o f my k n , ! ~ ) O 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 named 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 es u b s t a n t i a l l y s i m i l a r t o I o w a C o d e s e c t i o n 6 8 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 made . 1 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 made 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 e p 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 w a C o d es e c t i o n 6 8 A . 1 5 , u n l e s s t h e I o w a r e c i p i e n t c o mmi t t e e 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 mi 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 h a s b e e n r i l e d w i t h t h e I o w a Et h i c s a n d Ca mp a i g n D i s c l o s u r e B o a r d w i t h i n 1 5 d a y 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 ., T o , Fal t e r - _ Sec r e t a r y - Tr eas u r e r 2 / 3 / 2 a 0 f i( P e r s o n s u b mi t t i n g f o r m ) ( T i t l e ) ( D a t e )

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COMMI TTEE PARENT ENT I TY, AFFI L I ATE, SPONSOR OF COMMI TTEE( U s e s e p a r a t e p a g e i f needed t o l i s t mo r e t h a n o n e e n t i t y )

F . E . C . Name o f J u r i s d i c t i o n I BEW Name9 9 9 E S t r e e t , NW M a i l i n g A d d r e s s 9 0 0 Se v e nt h S t r e e t , NWMa i l i n g A dd r e s s

C t ~ ' a s ~ t b&2 0 4 6 3 T a l e ) 6 9 4 - 1 1 3 7 Wa s h i n g t o n , DC 2 0 &t y , S t a t e , Z i p Code


19/30

COMMI TT EE NAME

' A ETHI CS AND CAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1 ADES MOI NES, I A 5 0 3 1 9www . l o w a . g o v / e t h i c sF I ED STATEMENT REGI STRATI ON


F F I E D 3 T4 T: M ~MMI TTEE :

( O u t - o f - S t a t e Co mmi t t e e )

_. .. l n n_ F_ . Wal t er s _ _ Secretary-Treasurer( P e r s o n s u b m i t t i n g f o r m ) ( T i t l e )

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

O 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 am e .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) PAC1 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 , DC %Ob ? t e ' Z i p C o d e

W r i t t e n e x p l a n a t i o n m u s t b e p r o v i d e d f o r A c r o n y m ) .

C o d , 7 2 8 - 6 T X e p h o n e ' o -

STATE OR FEDERAL J URI SDI CTI ON WHERE COMMI TTEEI S REGI STERED OROPERATES ( U s e s e p a r a t e p a g e i t 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 )

PARENT ENTI TY, AFF I L I ATE, SPONSOR OFCOMMI TT EEName o f J u r i s d i c t i o nF e d e r a l E l e c t i o n C o n t m t s s i o n

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I BEW Name1 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 , DC 2 0 0 8 5 - ' S t a t e , Z i p C o d e

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n a r y

Name o f C o m m i t t e eJ o a n Mc Ca l man t f o r L i n n Co u n t y Re c o r d e rM a i l i n o A d d r e s s2 2 0 4 De b a n n L a n e NE , Ceda r R a p i d s , I A 5 2 4 0 2

0 1 / 1 8 / 2 0 0 6$ 1 0 0 . 0 0

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a f t t h a 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 l emmr t t 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 e s t o f my e d g e . I 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 es u b s t a n t i a l l y s i m i l a r t o I o wa C o d e s e c t i o n 6 &1 . 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 m a 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 was m a 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 ce p 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 C o d es e c t i o n 6 8 A. 1 5 , u n l e s s t h e I o wa r e c i p i e n t c o mmi t t e e i s a b a l l o t i s s ue c o mmi t t e e . I u n de 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 ma y a pp l y u n l e s s a c o p y o ft h i s f o r m ha s b e e n B l e d w i t h t h e I o wa Et h i c s a n d Ca mp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 1 / 1 8 / 2 0 0 6

( D a t e )


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COMMI TTEE NAMEO f f i c i a l Name o f O u t - o f - S t a t e C ommi t t e e ( Do n o t a b b r e v i a t e c o mmi t t e e name . Wr i t t e n e x p l a n a t i o n mus 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 Br o t h er h o o d o f E l e c t r i c a l Wo r k e r s ( I B EW)

9 0 0 S ev e n t h S t r e e t , NW M a i l i n g A d dr e s sWa s h i n g t o n , DC C ~ %Ob y t e , Z i p C o d e l ~ L C o d e 7 2 8 - 6 ab ' p h o n e No .

STATE OR FEDERAL J URI S DI C TI ON WHERE COMMI TTEEI S REGI STEREDOR OPERATES



C i t y , S t a t e , Z i p C o d eDes Mo i n e s , I A


COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPL I CATE .S END A COPY TO THE BOARDWI THI 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 REFERTO DETA I LED I NSTRUCTI ONS ON BACK OF FORM.THI S FORMMUST BE F I L ED FOR EACHCONTRI BUTI ON I N EXCESS OF $ 5 0

I OWA ETHI CS AND CAMPA I GN DI SCL OSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1 ADES MOI NES, I A 5 0 3 1 9www. l o w a . g o v / e t h i c s2OVERI F I ED STATEMENT REGI STRATI ON



1 4 3 5 N. E . 5 4 t h A v e n u e

( O u t - o f - S t a t e Commi t t e e)


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PARENT ENTI TY, A FF I L I A TE, SPONSOROF COMMI TTEE( U s e s e p a r a t e p a g e i f nee de d t o l i s t mo r e t h a n o n e e n t i t y )Name

900 S ev e n t h S t r e e t , NWa i l i n g A d d r e s s

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1 0/ 2 8 / 2 00 5

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$ 2 5 0 . 0 0

r y - T r e a s u r e r( P e r s o n s u b mi t t i n g f o r m ) ( T i t l e ) ( D a t e )

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C ommi t t e e . I D #8 0 2 6

1 J o n F . Wa l t e r s , a t t e s t t h a 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 nd t h a t t h e i n f o r ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t e e i s c o r r e c t a nd a c c u r a t e t o t h e b e s t o f my k n o wl e d ge . 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 omp l y w i t h r e q u i r e me n t s t h a t a r es u b s t a n t i a l l y s i mi l a r t o I o wa C o d e s e c t i o n 6 8 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 an d a l l e x p e n d i t u r e s made . 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 was made f r o m an a c c o u n t t h a t d o e s n o t a c c e p 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 C o d es e c t i o n 6 8 A . 1 5 , u n l e s s t h e I o wa r e c i p i e mi t t e e i s a b a l l o t i s s u e c o mmi t t e e . I u n d er s t a nd t h a t p o t e n t i a l c i v i l a n d c r i mi 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 h a s g 6 e n f i l e d w i t h , t h e I o wa E i s a n d C ampa i g n D i s c l o s u r e B o ar d w i t h i n 1 5 d a y 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 .


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COMMI TTEE NAME

I OWA ETHI CS AND CAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1 ADES 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 STRAT I ONCOMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPL I CATE .SENDACOPY TO THE BOARD WI THI N 1 5 DAYS OF THE CONTRI BUTI ON DATE AND

ONE COPY WI TH EACH CONTRI BUTI ON TO THE I OWA COMMI TTEE WI TH THE CONTRI BUTI ON .PLEASE REFER TO DETAI LED I NSTRUCT I ONS ON BACK OF FORM.THI S FORMMUST BE F I L ED FOR EACH CONTRI BUT I ON I N EXCESS OF $ 5 0

O f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( Do n o t a b b r e v i a t e c o mmi t t e e name . Wr i t t e n e x p l a n a t i o n mus t b e p r o v i d e d f o r Ac r o n y m) .I n t e r n a t i o n a l Br o t h er h o o d o f E l e c t r i c a l Wo r k e r s ( I B EW)9 0 0 Se v en t h S t r e e t , NW M a i l i n g A d d r e s sWa s h i n g t o n , DC C~%0 b y t e , Z i p Co d e

STATE OR FEDERAL J URI S DI CT I ON WHERE COMMI TTEEI S REGI STERED OROPERATES

F . E . C .9 9 9 E S t r e e t , NW

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1 4 3 5 N. E . 5 4t h A v e n u e

T y p e d Name o f I o w a R e s i d e n tM a i l i n g Ad d r e s s

C i t y , S t a t e , Z i p Co d e T e l e p h o n e5( 1 5 ) 2 6 5 - 6 19 4De s Mo i n es , I A

V ERI F I E D STATEMENT OF COMMI TTEE :I JonF. Wa I t e r s . a t t e s t t h a 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 ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t e e i s c o r r e c t an d a c c u r a t e t o t h e b e s t o f my k n o wl e d ge . 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 me n t s t h a t a r es u b s t a n t i a l l y s i m i l a r t o I o wa C o d e s e c t i o n 68A. 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 and a l l e x p en d i t u r e s made . 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 was made f r o m an a c c o u n t t h a t d oes n o t a c c e p 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 er 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 C o d e

s e c t i o n 6 8 A. 1 5 , u n l e s s t h e I o wa r e c i p i e n t c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e. I u n d er s t a nd 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 pp l y u n l e s s a c o p y o ft h i s f o r m h e s , b ee n r i l e d w i t h t h e I o wa r f f i r and Camp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y s o f t h e d at e o f t h e c o n t r i b u t i o n .


Da t e1 0 / 2 4 / 2 00 5Amo un t$ 5 0 0 . 0 0

, ~ 8 1 Co d e 7 2 8 - 6 ( ( ) T e p h o n e No .

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7 1 5

( T i t l e ) ( D a t e )

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PARENT ENT I T Y , AF FI L I AT E, SPONSOR OF COMMI TTEE( U s e s e p a r a t e p a g e i f neede d t o l i s t mo r e t h a n o n e e n t i t y )

I OWA COMMI TTEE RECEI VI NG CONTRI BUTI ONName o f Commi t t e e

Da v e Ho g a n f o r a Be t t e r Ceda r Ra p i d s


Commi t t e e . I D #8 0 2 6

Al l - Or r y - T r e a s u r e r 1 0 / 2 4 / 2 0 0 5


22/30


23/30

COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPLI CATE.SEND A COPY TO THE BOARD WI THI 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 DETAI LED I NSTRUCTI ONS ON BACK OF FORM .THI S FORM MUST BE F I LED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0COMMI T TEE NAME

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VtRIFIEDSTATEMENTREGISTRATION

O f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( D o n o t a b b r e v i a t e c o mmi t t e e na me . Wr i t t e n e x p l a n a t i o n mus t b e p r o v i d e d f o r Ac 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 W o r k e r s ( I BEW)9 0 0 S e v e n t h S t r e e t , NW M a i l i n g A d dr e s sWa s h i n g t o n , DC C 1 6 Ob y t e , Z i p Code

STATE OR FEDERAL J URI SDI CT I ON WHERE COMMI TTEEI S REGI STERED OR OPERATES

F E . C9 9 9 E S t r e e t , NWC&s f & P , i ~ F & 2 0 4 6 3



I OWA RESI DENT AGENTT y p e d Name o f I o w a R e s i d e n tS a n d y O p s t v e d t 1 1 Ka y H a l l o r a n f o r M a y o r

1 4 3 5 N. E . 5 4 t h A v e n u eC i t y , S t a t e , Z i p Code T e l e p h o n e I I I Da t eDe s Mo i n e s , I A

VERI F I ED STATEMENT OF COMMI TT EE :I J on F . Wnl t Pr s , a t t es t t h a 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 ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t 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 e s t o f my k n o wl e d ge . 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 named 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 es 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 de s e c t i o n 6 8 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 de . 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 de 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 e p 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 def t t e e i s a b a l l o t i s s u e c o mmi t t e e . 1 u n de 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 fCampa t n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 .s e c t i o n 6 8 A . 1 5 , u n l e ss t h e I o wa r e c i p i e n t ct h i s f o r m h a s b ee p l e d w i t h t h e I o wa E t h i c


Name o f J u r i s d i c t i o nM a i l i n g A dd r e s s

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) 6 9 4 - 1 1 3 7

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5( 1 5 ) 2 6 5 - 6 1 9 4 I I I 1 0 / 2 8 / 2 0 0 5Amo u n t$ 2 5 0 . 0 0

, ( ~ g 1 Code 7 2 8 - 6 0T p h o n e No

Name9 0 0 S e v e n t h S t r e e t , NWM a i l i n g A d dr e s sWa s h i n g t o n , DC 2 0 0 f f y , S t a t e , Z i p Code

Name o f Co mmi t t e eM a i l i n g A dd r e s s

8 2 5 1 7 t h S t r e e t S E , C e d a r R a p i d s , I A 5 2 4 0 3

Che c k #1 1 7 6 1

44 - l i d ~_Tr e a s ur e r _ 1 0 / 2 8 / 2 00 5n s u b mi t t i n g f o r m ) ( T i t l e ) ( D a t e )

Fo r m VERI FI ED 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 r o f f i c e u s e o n l yComm. #I n d e x e dA u d i t e dChe c k e dCompu t e r

PARENT ENTI TY, AFF I L I ATE, SPONSOR OF COMMI TTEE( U s e s e p a r a t e p a g e i f needed t o l i s t mo r e t h a n o n e e n t i t y )


I f I n - K i n d C on t r i b u t i o n , D e s c r i b eC o n t r i b u t i o n

Commi t t e e . I D #8 0 2 6


24/30

5 1 0 EAST 1 2 t h , SUI T E 1 ADES MOI NES, I A 5 0 3 1 9www. i o w a . g o v / e t h i c sVERI F I ED STATEMENT REGI S TRAT I ON( O u t - o f - S t a t e Co mmi t t e e )COMMI TTEES NOT ORGANI ZED I N I OWA TOCOMPLETE I N DUPL I CATE .SEND A COPY TO THE BOARD WI THI N 1 5 DAYS OF T HE CONTRI BUT I ON DATE ANDONE COPY WI TH EACH CONTRI BUT I ON T O T HE I OWA COMMI TTEE WI TH T HE CONTRI BUT I ON .PLEASE REFER TO DETAI LED I NSTRUCT I ONS ON BACK OF FORM.T HI S FORMMUST BE F I L E D FOR EACH CONTRI BUT I ON I N EXCESS OF $ 5 0

COMMI TTEE NAMEO f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( Do n o t a b b r e v i a t e c o mmi t t e e name .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 B EW)

9 0 0 S e v e n t h S t r e e t , NW M a i l i n g A d d r e s s





I OWA E T HI CS AND CAMPAI GN DI SCLOSURE BOARD

1 4 3 5 N . E 5 4 t h A v e n u e


M a i l i n g A d d r e s sC i t y , S t a t e , Z i p Code T e l e p h o neDe s M o i n e s , I A

VE RI F I E D STATEMENT OF COMMI TTEE :I , a t t e s t t h a 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 ec o m m i t t 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 e s t o f my k n o wl e d g e . I 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 named j u r i s d i c t i o n c o m p l y w i t h r e q u i r e m e n t s t h a t a r es u b s t a n t i a l l y s i m i l a r t o I o w a Code s e c t i o n 6 8 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 and a l l e x p e n d i t u r e s made . 1 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 made 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 e p 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 w a C o d es e c t i o n 6 8 A 1 5 , u n l e s s t h e I o w a r e c i c o mm i t t e e i s a b a l l o t i s s u e c o m m i 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 h~. s b e e n f i l e d i t h t h e l o w E t ' c s a n d C a mp a i g n D i s c l o s u r e B o a r d w i t h i n 1 5 d a y 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 .

5( 1 5 ) 2 6 5 - 6 1 9 4 D a t e1 0 / 2 4 / 2 0 0 5Amoun t5 0 0 . 0 0

r s ~. ~~t a r y - Tr e a s u r e r( P e r s o n s u b m i t t i n g f o r m ) ( T i t l e ) ( D a t e )

Fo r m VERI F I E DSTATEMENTREGI STRAT I ON( O u t - o f - S t a t e Co mmi t t e e s )( R e v . 0 7 1 0 3 )F o r o f f i c e u s e o n l yComm . #I n d e x e dA u d i t e dC h e c k e dCompu t e r

Wr i t t e n e x p l a n a t i o n mus t b e p r o v i d e d f o r A c r o n ym) .

I OWA COMMI TTEE RECEI VI NG CONTRI BUTI ONName o f Commi t t e eK a y H a l l o r a n f o r Mayor - C a n d i d a t e # 1 3 4 7 4

M a i l i n g A d d r e s s8 2 5 1 7 t h S t r e e t NE , C e d a r R a p i d s , l A 5 2 4 0 3I f I n - K i n d C o n t r i b u t i o n , D e s c r i b e

C o n t r i b u t i o nC h e c k #1 1 7 1 8 Commi t t e e . I D #8 0 2 6

Wa s h i n g t o n , DC" Mt f t e , Z i p Code

STATE OR FEDERAL JURI SDI CTI ONWHEREI S REGI STERED OR OPERATES

COMMI TT EE

Z~ Code - 7 2 8 - 6 T ~ e p h o n e No .

PARENT ENT I T Y , 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 mo r e t h a n o n e e n t i t y )

F E C Name o f J u r i s d i c t i o n I BEW Name9 9 9 E S t r e e t , NW M a i l i n g A d d r e s s 9 0 0 S e v e n t h S t r e e t , NWa i l i n g Ad d r e s s

~ V t ~ ' a s g t b l ~ ~ 5 & 2 0 4 6 3 T a l e ) 6 9 4 - 1 1 3 7 Wa s h i n g t o n , DC 2 0 C 8 1 t i ' S t a t e , Z i p Code


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b pWOWA ETHI CS AND CAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1 A1 DES MOI NES, I A 50 3 1 9www. l o wa . g o v / s t h i c s

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 mmi 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 m u 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 B EW) 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: M O b ? t 8 ' Z i p C o d e , C o d ; 7 2 8 - 6 ( ) 4 6 d o n e No .

STATE OR FEDERAL J URI SDI CTI ON WHERE COMMI TTEE PARENT E NT I T Y, AF F I L I AT E, SPONSOROF COMMI TT EEI S REGI STERED OR OPERATES ( 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 )

F e d e r a l E l e c t i o n C o mm i s s i o n u r i s d i c u o n I I B EW Name9 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 u l 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 s' ' a Ml a , b&2 0 4 6 3


1 4 3 5 N. E . 5 4 t h Av e .

T e l e

Sandy O p s t v e d tM a i l i n g A d d r e s s

T y p e d Name o f I o w a R e s i d e n t

STATENT F, O4 1 ~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 M o i n e s , I A 50313

6 9 4 - 1 1 3 7

1 5 2 6 5 - 6 1 9 4

Wa s h i n g t o n , DC 2 0 0 8 5 " ' S t a t e , Z i p C o d e

F 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 mm i t t e e s )( R e v . 0 7 / 0 3 )

No 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 COMMI TT EE RECEI V I NGCONTRI BUTI ONName o f C o mm i t t e e

Ka y H a l l o r a n Ca mp a i g nMa i g n o A d d r e s s1 8 2 5 1 7 t h S t r e e t , SE, Ce d a r Ra p i d s , I A 5 2 4 0 3

p o l e 0 8/ 1 5/ 2 0 05 C o n t r i b u t i o n

~ 8 i t 4 3t - i h9 wj 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 l s t a t ei s c o n e d a n d a c c u r a t e t o t h e b e s t o f my k n o wl e I a l s o a v a 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 es u b s t a n t i a l l y s i m i l a r t o I o wa Code s e c t i o n 6 &1 . 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 made . 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 was made f r o m a n a c c o u n t t h a t d oe s n ot 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 Codes e c t i o n 1 5 , u n l e s s t h e I o wa r e d ' c o m r n i t t e a i s a b a l l o t i s s u e c o mmi t t e e . 1 u n de 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 b e e n f i l e d 7 h t h e t o E a n d Camp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y 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 ./ c i Secretary-Treasurer ~ 0 8/ 1 5/ 2 0 05__

( r ue) ( D a t e )

VERI F I ED STATEMENT REGI STRATI ON F o r o f f i c e u s e o nl y( O u t - o f - S t a t e Co mmi t t e e ) Comm. #I n d e x e d~- _COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPLI CATE .SEND A COPY TOTHE BOARD WI T H I N 1 5 DAYS OF THE CONTRI BUTI ON DATE AND A u d i t e dONE COPY WI TH EACH CONTRI BUTI ON TO THE I OWA COMMI TTEE WI TH THE CONTRI BUTI ON . C h e c k e dPLEASE 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 E D FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0 C o mp u t e r _


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COMMI TTEE NAME

STATE OR FEDERAL JURI SDI CT I ON WHERE COMMI TTEEI S REGI STERED OROPERATES



O f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( Do n o t a b b r e v i a t e c o mm i t t e e nameI n t e r n a t i o n a l Br o t h er h o o d o f E l e c t r i c a l Wo r k e r s ( I B EW)9 0 0 Se v e nt h S t r e e t , NW M a i l i n g A d dr e s sWa s h i n g t o n , DC CMOby t e , Z i p Code

Wr 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 ym) .

P~ Code 7 2 8 - 6 ( 7 f 4 e p h o ne No .

F . E . C .9 9 9 E S t r e e t , NW

a s f t g j V ' bVe 2 0 4 6 3

Name o f J u r i s d i c t i o nM a i l i n g A d dr e s s

T e l e ) 6 9 4- 1 1 3 7

I BEW Name9 0 0 Se v e nt h S t r e e t , NWM a i l i n g A d d r e s sWa s h i n g t o n , DC 2 0 0 Rt y , S t a t e , Z i p Code

No n - P ar t i s an P o l i t i c a l L e a g u e

1 1 Sandy Op s t v e d t

1 4 3 5 N. E . 5 4t h A v e n u e

Typed Name o f I o w a R e s i d e n t

M a i l i n g A d d r e s sC i t y , S t a t e , Z i p Code T e l e p h o n eDe s Mo i n e s , I A 5( 1 5 ) 2 6 5- 6 1 9 4

Name o f Co mmi t t e eTa r a Yo u el l s f o r Co u n c i l

M a i l i n g A d d r e s s1 6 2 2 A r i z o na A v e n u e NE, Ceda r Ra p i d s , I A 5 2 4 0 2

D a t e1 1 / 1 8 / 2 00 5Amou n t$ 2 5 0 . 0 0

I f I n - K i n d C o n t r i b u t i o n , D e s c r i b eCo nt r i b ut i o nChe c k # Commi t t e e I D #1 1 9 2 0 18026

COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPL I CATE .SEND A COPY TO THE BOARDWI THI N 1 5 DA Y S OF T HE 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 DETAI LED I NSTRUCTI ONS ON BACK OF FORM.THI S FORMMUST BE F I LED FOREACH CONTRI BUTI ON I N EXCESS OF $ 5 0

ETHI CS AND CAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2t h , SUI TE 1ADES MOI NES, I A 50319www. l o wa . g o v / e t h i c sI ED STATEMENT REGI STRA TI ON

( Ou t - o f - St a t e Commi t t ee)

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 ma t i o n a b o u t t h i s o u t - o f - s t a t ee e i s c o r r e c t a n d a c c u r a l e- t o t h e b e s t y k n ow / e . I 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 named 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 es u b s t a n t i a l l y s i m i l a r t o I o w a C o d e s e c t i o n 6 8 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 an d a l l e x p e n d i t u r e s made 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 mad 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 e p 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 w a C o d es e c t i o n 6 8 A . 1 5 , u n l e s s t h e I o w a r e c i p t c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e . I u n d er s t a nd t h a t p o t e n t i a l c i v i l a n d c r i mi 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 h 0 & been f i l e d w i t h t h e l o w ; E l f i c s a n d Ca mp a i g n D i s c l o s u r e B o a r d w i t h i n 1 5 d a y 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 .- o n s u b mi t t i n g m) a r y - Tr e a s u r e r ( T i t l e )

Fo r m VERI F I ED STATEMENTREGI STRATI ON( O u t - o f - S t a t e C o mm i t t e e s )( R e v 0 7 1 0 3 )F o r o f f i c e u s e o n l y ,Comm . #I n d e x e dA u d i t e dChe c k e dCompu t e r

PARENT ENTI TY , A FF I L I A TE, SPONSOROF COMMI TTEE( U s e s e p a r a t e p a g e i f needed t o l i s t mo r e t h a n o n e e n t i t y )


1 1/ 1 8/ 2 00 5( D a t e )


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COMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPL I CATE.SEND A COPY TO THE BOARD WI T HI N 1 5 DAYS OF THE CONTRI BUT I ON DATE ANDONE COPY WI TH EACH CONTRI BUTI ON TO THE I OWA COMMI TTEE WI TH THE CONTRI BUT I ON .PLEASE REFER TO DETAI LED I NSTRUCTI ONS ON BACK OF FORM .T H I S FORM MUST BE F I L EDFOR EACH CONTRI BUT I ON I N EXCESS OF $ 5 0COMMI TTEE NAME

I OVNA, ETHI CS AND CAMPAI GN D I SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI T E 1 ADES MOI NES, I A 5 0 3 1 9www. i o w a . g o v / e t h i c s

VERI FI FED STATEMENTREGISTRATION( O u t - o f - S t a t e Co mmi t t e e )

O f f i c i a l Name o f O u t - o f - S t a t e C o mmi t t e e ( D o n o t a b b r e v i a t e c o mmi t t e e name .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)9 0 0 Se v e n t h S t r e e t , NW M a i l i n g A d d r e s sWa s h i n g t o n , DCC%b y t e , Z i p C o d e

W r i t t e n e x p l a n a t i o n m u s t b e p r o v i d e d f o r A c r o n y m ) .

S ~ Co d 7 2 8 - 6 ( T X b e p h o n e No .

STATE OR FEDERAL J U RI S DI CT I ON WHERE COMMI TTEEI S REGI S TERED OROPERATES

F . E . C . Name o f J u r i s d i c t i o n I I I I BEW9 9 9 E S t r e e t , NW

G a s ' # f t & P , X20463 T e l e 69 4 - 1 1 3 7



I OWA RES I DENT AGENTS a n d y O p s t v e d t

1 4 3 5 N. E . 5 4 t h A v e n u 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 e I I I D a t eDe s Mo i n e s , I A 5( 1 5 ) 2 6 5 - 6 1 9 4 1 1 1 6 / 8 / 2 0 0 5Amo u n t$ 5 , 0 0 0 . 0 0

PARENT ENT I T Y, AF FI L I AT E, SPONSOR OF COMMI TTEE( 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 mo r e t h a n o n e e n t i t y )Name

9 0 0 Se v e n t h S t r e e t , N WMa i l i n g A d d r e s sC i t y , S t a t e , Z i p C o d eWa s h i n g t o n , DC 2 0 0 o r

I OWA COMMI TTEE RECE I V I NG CONTRI BUT I ONName o f C o mm i t t e e

C i t i z e n s f o r a B e t t e r Ce da r R a p i d s : V o t e Home Ru l eM a i l i n g A d d r e s s1 2 1 1 Wi l e y B l v d SW, Ce da r R a p i d s , I A 5 2 4 0 4

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