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FOR I NSTRUCTI ONS, SEESACK OF FORM

DI SCLOSURESUMMARYPAGE

COMMI TT EE NAME ( Mu s t b e s a r n e a s o n St a t e me n t of O r g a n i z a t i o n )

_&14" pga "w)

I MPORTANT I n d i c a t e t y p e o f c o m m i 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 ( d ) C o u n t y / L o c a l C an d i d a t e

( 5 ) C o u n t y PA C ( 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 ) C o u n t y / C i t y C e n t r a l C o mmi t t e e

CANDI DATE COMMI TTEES ONLY :

C a n d i d a t e Na me P o l i t i c a l P a r t y

s y p ~ ~ ~ L r y \ Qc . r a k

O f f i c e S o u g h t D i s r i c t ( i f Se n a t e o r H o u s e )

hl a Xcc,

SURER( o r p e r s on f i l i n g t h i s r e p o r t )

Re s e t Fo r m

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 o s 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 .

SEE I NSTRUCTI ONS ON BACK AND OMPLETE THE FOLLOWI NG SENTENCE :

I AM F I L I N G A REPORT FORAN/ A ( t ) ELECTI ON / ( 2 ) NON- ELECTI ON YEAR .( r e p o r t d a t e ) I n d i c a t e on e

[ CHECK I F AMENDMENT TOREPORT DATED

( 1 Check i f 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 or m DR- 3 .

( Y o u m u s 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 CASHON 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 mo n i e s h e l d

b y t h e c o mm i t t e e . T h i s amoun t MUST b e t h e s ame a s t h e c a s h o n h an d a t t h e en 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 s 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

S c 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 S c 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 ) . . . . . . . . . .S c h e d u l e F : L o a n s R e c e i v e d t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c h e d u l e H : T o t a l S a l e s o f Campa i g n P r o p e r t y ( A t t a c h S c h e d u l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( S c h e d u l e H a p p l i e s t o C a n d i d a t e s ' Commi t t e e s On l y )

SUBTOTAL . . . . . $

SUBTRACT TOTAL MONEY SPENT THI S PERI OD

S c 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 S c h e d u l e B ) ( * * a l s o s e e d e b t s a n d l o a n s b e l o w ) . . . .

S c h e d u l e F : L o a n Repa ymen t s t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CASHON HAND a t t h e en 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 m u s t

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

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 n

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* I N K I ND CONTRI BUTI ONS ( F r o m S c h e d u l e E - A t t a c h S c h e d u l e E $ ~ ` J r l" $a) . . . . . . . . . . . . . . . . . . . . . . . . . . . --

* OUTSTANDI NG LOANS ( F r o m S c h e d u l e F - A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

CANDI DATE COMMI TT EES ONLY ,

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

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



F o r I n s t r u c t i o n s , S e e B a c k o f F o r m

CONTRI B UT I ONS - MONEY TAKEN 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 TTEENAME ( Mu s t be s ame a s on St t e r n e n t o f Or g an f z t i o n

Rese t : F o r m` '

STATE CANDI DATES NOTE : I F A CONTRI BUT I ON I S RE6E I VED FROMA STATE PAC ( POL I T I CA L ACT I ON COMMI TTEE) . L I S T THE PAC I DENT I F I CAT I ON

NUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN. A L I S T OF I D NUMBERS I S AVA I L A B L E FROM THE I OWA ETHI CS AND CAMPA I GN

DI SCL OSURE BOARD.

CAUTI ON: Se c t i o n 68B . 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 mat i o n c o pi 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 on t r i b ut i o ns o r

f o r any c o mme r c i a l p u r p o s e b y any 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 e s .

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c o mmi t t e e R e l a t i o n s h i p mu st b e s h o wn t o t h e t h i r d d e gr 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 ) an d a f f i n i t y ( r e l a t i v e s b y

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Fo r I n s t r u c t i on s , See Ba t i 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 TTEENAME ( Mu s t b e s ame a s on S t a t e me n t o f O r g a n i z a t i o n )

Re s e t Fo r m

_ . t

STATE CANDI DATES NDTE : 1 I = A CONTRI BUT I ON I S RECEI VED FROM A STATE PAC ( P OL I T I C AL ACT I O N COMMI T T E E ) , L I S T THE PAC I D EN T I F I C A T I O N

NUMBER AND TH E PAC CHECKNUMBER I N TH E D E S I C , N A T E D COLUMN . A US T OF I D NUMBERS I S A V AI L A B L E FROM THE I OWA E T HI C S AND CAMPAI GN

DI SCLOSURE BOARD .

CAUTI ON S e c t i o n 6 8 B . 3 2 A ( 6 ) , l o ws 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 e d f r o m r e p o r t s a n d s t a t e m e 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 r

f o r a n y c omme r c i a l p u r p os e b y a n 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 .

SUB- TOTAL

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SCHEDULE

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( Re v . 0 7 / 0 3 ) RECEI P TS

QCHECK T HI S BOX I F

AMENDI NG FORM

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c o m m i t t e e . R e l a t i o n s h i p m u s t b e s h ow 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

m a r r i a g e ) I f s u r n a m e 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 o P a g e o f -~- _

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 " r 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 . ( f o r S c h e d u l e. Af ~

DATE PAC I D NUMBER NAMEANDADDRESSOF CONTRI BUTOR RELATI ONSHI P

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Fo r I n s t r u c t i on s , Se e 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 TTEENAME ( Mu s t b e s ame a s on St a t e me n t o f O r g a n i z a t i o n )

f o r a n y c o mme r c i a l p u r p o s e b y a n 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 .

R e s e t . F o r m '

D i s c l o s u r e f e 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 ec o mmi t t e e . R e l a t i o n s h i p m u s t b e s h o wn 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 ) . I f s umame o f c o n t r i b u t o r i s t h e s am e a s c a n d i d a t e , b u t t h e r e i s n of 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 .

SUB- TOTAL

TOTAL ( i f l a s t page o f t h i s s c h ed u l e )

SCHEDULE

A MONETARY

( R e v . 0 7 / 0 3 ) RECE I PTS

El CHECK T HI S BOX I F

AMENDI NGFORM

NUMBER 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 E T HI C S 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 ma t i o n c o p i e d f r o m r e p o r t s a n 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 r

STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P O L I T I C A L ACTI ON COMMI T T E E ) , L I S T THE PAC I D EN T I F I C A T I O N

Pa ge o f _~( f o r S c h e d u l e A)

DATE PAC I D NUMBER NAMEANDADDRESS OF CONTRI BUTOR RELATI ONSH I P AMOUNT 4 I F FRECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECE I VED FUND( MM/ DD/ YR) ANDPACCHECK ( i f a p p l i c a b l e ) RAI S

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FOR I NSTRUCTI ONS, SEE BACK OF FORM R e s e t Fo r m

EXPENDI TURES - - MONEY SPENT FROMCOMMI TTEE ACCOUNT

STATE PAC COMMI TTEES : NOTE : FORCONTRI BUTI ONSMADE TOSTATEWI DEOR LEGI SLATI VE

CANDI DATES, L I ST THECANDI DATE I DENT I F I CATI ON NUMBER I N THEDESI GNATED COLUMN AND THE

PAC CHECKNUMBER FOREACH EXPENDI TURE . A L I ST OF I D NUMBERS I S AVAI LABLEFROMTHE I OWA

ETHI CS &CAMPAI GNDI SCLOSURE BOARD .

SCHEDULE

B MONETARY

( Re v . 0 7 / 0 3 ) EXPENDI TURES

CHECKTHI S BOXI F

AMENDI NG FORM

COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f , , " a n i z a t i o n )

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THI S BOXAPPLI ESTO CANDI DATES' COMMI TTEES ONLY :

P ur c h a s e s o f o s 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 5 0 0 o r mo r e mus t a l s o b e i n v e n t o r i e d o n Sc h e d u l e H_ ( Re f e r t o Sc h e d u l e Hi n s t r u c t i o n s . )

Ex p e nd i t u r e s t o p er s o n s l 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 , 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 mus t a l s o be d e t a i l i t e mi z ed o nSc h e d u l e Gby t h e a mo u n t , p u r p o s e , and d a t e o f e a c h t y p e o f e x pe nd i t u r e made by 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 nd i d a t e ' s c o mmi t t e e . ( R e f e r t o

Sc h e d u l e G i n s t r u c t i o n s a n d I o wa Co d e 68A. 4 0 2 ( 3 ) ( i ) . )

( f o r Sc h e d u l e B)

CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE

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

EXPENDED ( i f a p p l i c a b l e ) ( Di s b u r s e me n t ) WASMADE

( MM/ DD/ YR) AND PAC

CHECKNUMBER



THI S BOXAPP I L I E S 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 00 o r mo r e mus t a l s o b e i n v e n t o r i e d o n Sc h e d u l e H. ( R e f e r t o Sc h e d u l e H i n s t r u c t i o n s . )

Ex p e nd 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 mus t a l s o b e d e t a i l i t e mi z e d o nSc h e d u l e Gb y t h e amo u n t , p u r p o s e , and d a t e o f e a c h t y p e o f e x pe nd i t u r e mad e b y t h e Pe r s o n/ e nf t y o n b eh a l f o f t h e c a nd i d a t e s c o mmi t t e e . ( R e f e r t oSc h e d u l e Gi n s t r u c t i o n s a n d I o wa Cod e 66A. 4 0 2 ( 3 ) ( i ) . )

Pa g e ~ - 2 - o f

FOR I NSTRUCTI ONS, SEE BACK OF FORM Rese t Fo r t hSCHEDULE

EXPENDI TURES B MONETARY- - MONEY SPENT FROMCOMMI TTEE ACCOUNT

( Re v . 0 7 / 0 3 ) EXPENDI TURES

STATEPACCOMMI TTEES : NOTE : FORCONTRI BUTI ONSMADE TO STATEWI DEOR LEGI SLATI VE

CANDI DATES, L I ST THECANDI DATE I DENT I F I CATI ONNUMBER

I N THE DESI GNATED COLUMN ANDTHE CHECKTHISBOXI F

PACCHECKNUMBER FOREACH EXPENDI TURE. A L I STOF I D NUMBERS I S AVA I LABLE FROMTHE I OWA AMENDI NGFORM

ETHI CS&CAMPAI GN DI SCLOSURE BOARD .

COMMI TT EE NAME ( Mu s t b e s ame a s o n St a t eme n t o f O r g a n i z a t i o n )

Z' ?t f ) /i

CANDI DATE NAME ANDADDRESSTO OM PURPOSE AMOUNT

DATE I D NUMBER EXPENDI TURE ( DESCRI BETRANSACTI ON) EXPENDED

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FORI NSTRUCTI ONS, SEEBACKOF F ORA i f SCHEDULE

( Re v . ( 1 8 1 3 8 )~. T f WENAME ( Mu s t b e s a me a s St Or g a n i z a t i o n )

e t l e , , r r : ~ p

NOTE: De b t s p r e v i o u s l y r e p o r t e d t h a t r e ma i n u n p ai d mu s t b e i n c l u d ed o n t h i s

Sc h e d u l e , a s w e l l as a n y newo b l i g a f r o n s i n c u r r e d i n t h i s p e r i o d .R e s e t Fo r m

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( DONOT I NCLUDE LOANS - - SHOWLOANSON SCHEDULE F ) r e c e i v e d , b u t n ot p ai d f o r b y t h e

end o f t h e r e p o r t i n g p e r i o d . ,

r e g a r d l e s s o f wh e t h e r an i n v o i c e

h a s b e e n r e c ei v e d

' I f a c t u a l f i g u r e i s u n k n o w n , s h o w " e s t i ma t e d " b es i d e t h e f i g u r e . P a g e o f( c h e d u l e Dj

CANDI DATE COMMI TTEESNOTE:

" I n c u r r e d i n d eb t e d n es s a l s o I n c l u d e s e a c h p e r s o r d e n t i t y w i t h w h o m t h e c a n d i d a t e ' s c o mmi t t e e h as e n t e r e d f i b a c o n t r a c t d u r i n g t h e r e p o r t i n g p e r i o d f o r f u t u r eo r c o n t i n u i n g p e r f o r ma n c e . E n t e r t h e n a me o f t h e c o n s u t t a n to r g a n i z i n g s e r v i c e s . R e po r t on Sc h e d u l e G t h e n a t u r e o f

who p r o v i d e s o r p r o c u r e s s e r v i c e s f o r i t e ms s u c h as a d v e r t i s i n g , f u n d - r a i s i n g . p o t t i n g , ma n a g i n g , ap e r f o a r t a n c e a n d t h e e s t i ma t e d p e r f o r ma n c e r e a s o n ab l y e x p e c t e d o f t h e c o n s u l t a n t .

DATEI NCURRED

( MM/ D DI Y R)

NAMEANDADDRESSOF PERSON

TOWHOMDEBT OROBLI GATI ON I SOWED

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FORI NSTRUCTI ONS, SEEBACK OF FORM

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s c h ed u 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 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 an y r e l a t i v e ma k i n g a n i n k i n d c o n t r i b u t i o n t o t h ec o mmi t t e e . R e l a t i o n s h i p must 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 sb y m a r r i a g e ) . ( S e e Pa g e 2 o f f o r ms p a c k e t . ) I f s u mame o f c o n t r i b u t o r i s t h e same 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 .

SCHEDULE

( Re v . 0 6 1 9 7 ) 1E I N K I ND

CONTRI BUTI ONS

QCHECKTHI S BOX I F

AMENDI NG FORM

DATERECEI VED( MMI DDI YR)

NAMEAND ADDRESS

OF C TRI BUTOR

RELATI ONSHI PTOCANDI DATE

' ( i f a p p l i c a b l e )

DESCRI PTI ONOF I N K I ND

CONTRI BUTI ON

ESTI MATEDFAI R MARKET

VALUE

4 I F FORFUND- RAI SERCONTRI BUTI ON

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l i t

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t

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i l k i

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