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FORI NSTRUCTI ONS, SEE BACK OF FORM

COMMI TTEE NAME ( Mu s t b e same a s o n St a t eme n t o f O r g a n i z a t i o n )l k z ; r - 9 ~ t h l 2~~ 5 1 0 1 - '

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FOR I NSTRUCTI ONS, SEE BACKOF AM SCHEDULEEXPENDI TURES B MONETARY- MONEY SPENT FROM COMMI TTEE ACCOUNT ( Re v . 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FORCONTRI BUTI ONS MADE TOSTATEWI DE ORLEGI SLAT I VECANDI DATES, L I ST THE CANDI DATE I DENTI F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE 7 CHECK T HI S BOX I FPAC CHECK NUMBERFOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA AMENDI NG FORMETHI CS t : CAMPAI GN DI SCLOSURE BOARD .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)

FAf 1 Jr m , ewCAND I DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCR I BE TRANSACT I ON ) EXPENDEDEXPENDED ( d a p p l i c a b l e ) ( D i s b u r s e me n t ) WAS MADE( MM/ DDf YR ) AND PACCHECKNUMBER

/ d 1D# e(5 l c;9~ 6 , 6 1 w1 c7a CK# . -l 3 / ~ l ~ AVI D #

CK#I D #C K #I D #CK#I D #C K #I D #

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FOR I NSTRUCTI ONS, SEE BACK OF FOR

NOTE : D e 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 a i d mus t b e i n c l u d e d o n t h i sS c h e d u l e , a s w e l l a s a n y n e w o b l i g a t i o n s i n c u r r e d i n t h i s p e r i o d .

SCHEDULED I NCURRED( Re v . 0 8 / 9 8 ) 1 I NDEBTEDNESSCHECK T HI S BOXI F AMENDI NGFORM

An " i n c u r r e d d e b t ' i s a d e b t f o rDEBTS / OBL I GAT I ONS REMA I NI NG T HI S REPORTI NG PER I OD

g o o d s o r s e r v i c e s o r d e r e d o r( DO NOT I NCLUDE LOANS - SHOWLOANS ON SCHEDULE F )

r e c e i v e d , b u t n o t p a i d f o r b y t h ee n d 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 a n i n v o i c eh a s b e e n r e c e i v e d .

DATEI NCURRED( MM/ DD/ YR) NAME AND ADDRESS OF PERSONTO WHOM DEBT OR OBL I GAT I ON I S OWED

DESCRI PT I ON OF GOODS ORSERVI CES PROVI DED ORPURCHASED

BALANCE OWED ATCLOSE OFREPORTI NGPERI OD"

r%GO V

1/ o -2 j , ~L , 0 1 , _ y t$

660 , c k - )

G { g y f A~ ~zg S~ Z

~ o Zd ~X61 ( / ~ ~ ~ vS-DDO 7 , c e Wr r f S " l a z

I

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FOR I NSTRUCT I ONS, SEE BACK OF FORMCOMMI TTEE NAME( Mus t b e s ame a s o n S ( a f e r n e n t o f O r g a n i z a t i o t o

NOTE : T h i s s c h e d u l e r e p o r t s money l o a n e d t o t h e c o mm i t t e e w h i c h I s d e p o s i t e d i n t h e c o mm i t t e e a c c o u n t.TOTAL UNPA I D LOANS FROM I=REPORT I NGPERI OD $PART I - MONETARY LOANS RECEI VED I =REPORT I NG PERI OD( O r i g i n a l s o u r c e o f l o a n , s u c h a s a b a n k , mus t b e s h ow n I f a MWp a r t y I si n v o l v e d I n c l u d e l o a n s f r o m c a n d i d a t e ' s p e r s o n a l f u n d s . )

TOTAL ( P ART I )

' D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mmi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v ema k i n g a c o n t r i b u t i o n t o t h e c o mmi t t e e . R e l a t i o n s h i p mu 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 fC o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b y ma r r i a g e ) . ( S e e P a g e 2 o f f o r m sp a c k e t . ) I t 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 am e a s c a n d i d a t e , b u t t h en i s n o f a mw s lr e l a t i o n s h i p , e n t e r - n o t a p p l i c a b l e ' i n t h e r e l a t i o n s h i p c o l u mn w h e n k a p p l i e s .

PART I I - MONETARY LOAN REPAYMENTS MADE I MREPORT I NG PERI OD( L o a n s f o r g i v e n mus t b e r e p o r t e d o n S c h e d u l e E - - I f - k u i d C o n t r i b u t i o n s . )

TOTAL CASH REPAYMENTS ( P ART 1 1 )

$

Or e m S c h e d u l e E - - TOTAL LOANS FORGI VENTOTAL OUTSTAND I NG LOANS END OF REPORT PERI OD

SCHEDULEF LOANS( R e v . 0 1 1 1 % )

RECEI VEDa REPA I DpCHECK T HI S BOX I FAMENDI NG FORM

P a g e - . - - - - L o f( ( . , . Sr . I j e d n l " . r l

DATERECEI VED( MMJ DD / Y R )NAME AND ADDRESS OF LENDER( I n c l u d e E n d o r s e r ' s Name , I f A p p l i c a b l e ) RELAT I ONSHI PTO CAND I DATEI f A p p l i c a b l e - )

AMOUNTOF LOAN_DATE P AI D( MMI DDI YR) NAME AND ADDRESS OF LENDER( I n c l u d e E n d o r s e r ' s Name, I t A p p l i c a b l e ) RELATI ONSHITO CANDI DATE'( I t A p p l i c a b l e )

AMOUNTREPA I D

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r u r c I N J I RUCTI ONS, SEE BACK OF FORMT HI S FORMI S USED BY CANDI DATES' COMMI TTEES ONLY

COMMI TT EE NAME( Mus t b e same a s o n S t a t e me n t o f O r g a n i z a t i o n )

PART I I - I T EMI ZED BREAKDOWN OF UNREI MBURSED EXPENSES PA I D BY CONSULTANTTO OTHERS I N PERFORMI NG SERVI CES OF CONTRACT ( T h e s e e x p e n s e s s h ou l d NOT b ePART I - NAME AND ADDRESS OF CONSULTANT

r e p o r t e d o n S c he d u l e B , a s t h e y a r e d i r e c t p a yme n t f r o m t h e c o n su l t a n t . )

Name o f Co n s u l t a n tFAZ ~ / /

, A ,n g Ad d r e s s

SD o o

r 1

~a . ~

'

/ yZ

C i t y

S t a t e

Zi p Cod e

pa - t , z. 4

S - z a n 7

TOTAL ANT I CI P ATEDCOMPENSATI ON FORCONTRACT PERI OD ( MM/ DD/ YR)

PERFORMANCE

Fr o m J ~J AVT o ! 1 ? ~EST I mATES OF PERFORMANCE

P a g e-~o ff o r S c he d u l e G)

SCHEDULEG BREAKDOWNOF MONET ARY( Re v . 0 2 / 9 6 ) EXPENDI TURESBY CONSULTANT

CHECK T HI S BOX I FAMENDI NG FORM

DATEEXPENDEDMM/ DD/ YR NAME AND ADDRESS TO WHOMEXPENDI TURE( D i s b u r s e me n t ) WAS MADE AMOUNTPURPOSE EXPENDED

a

SUB- TOTAL

TOTAL ( I f l a s t p a g e o f t h i s s c h e d ul e )