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FOI L I NSTRUCTI ONS, SEE BACK OF FORMr

DI SCLOSURE SUMMARY PA

[ ] CHECKI FAMENDMENTTOREPORTDATED

( t ) S t a t e w i d e / L e g i s l a t i v eC a n d i d a t e( 2 ) S t a t e w i d ePAC ( 3 ) S t a t eP a r t y( 4 ) C o u n t y / L o c a lC a n d i d a t e( 5 C o u n t yPAC ( 6 ) B a l l o tI s s u e / F r a n c h i s eC o m m i t t e e( 7 ) C o u n t y / C i t yC e n t r a lC o mmi t t e e( 4 / ) S u p p o r tS t a t eo fC a n d i d a t e

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SI GNATUREOF TREASUR ( o rp e r s o nf i l i n gt h i s r e p o r t ) TELEPHONE

P e n a l t i e sDu e Fo rL a t eF i l e dRep o r t sRange f r o m$ 1 0 t o $400

SEE I NSTRUCTI ONS ON BACKAND COMPLETETHEFOLL OWI NGSENTENCE:

I AM F I L I N GA l ~~ o ZQ0 / REPORTFORAN/ A( 1 )ELECTI ON/ ( 2 ) NON- ELECTI ONYEAR.

( r e p o r td a t e ) I n d i c a t eo n e

C ]Checki ft h i si sf i n a l( t e r mi n a t i o n ) r e p o r ta n da t t a c hN o t i c eo fD i s s o l u t i o nF o r mDR - 3.( Yo um u s tc o n t i n u et of i l er e p o r t su n t i la N o t i c eo fD i s s o l u t i o ni sf i l e d. )

STATEMENT OF CASH ON HAND

CASHON HANDa t t h eb e g i n n i n go f t h er e p o r t i n gp e r i o d. ( T h i si st h et o t a lo fa l lmo n i e sh e l db yt h ec o m m i t t e e. T h i sa m o u n tMUSTb e t h es ame a s t h ec a s ho n h an da t t h ee n do ft h el a s tr e p o r t i n gp e r i o d ,o rm u s tb ez e r oi ft h i si sf i r s tr e p o r tf i l e d. ) .. .. . .. . .. .. .. .. .. .. .. .. .. .. .. .. .. . ... .. .. .. .. .. .. . . . . . .. .. .. .. .. .. .. . . ... .. $

ADDTOTALMONEYTAKENI NTHI SPERI ODS c h e d u l eA: CashC o n t r i b u t i o n st o t a l( A t t a c hS c h e d u l eA) .. . .. . . .. .. .. . . .. .. .. .. .. . . . . .. . . . . . . . . . . .. .. . .. .

S c h e d u l eF: L o a n s Re c e i v e dt o t a l( A t t a c hS c h e d u l eF ). .. . . . .. .. . . . . . .. .. . . .. . . .. .. .. .. . . .. .. . . . . .. .. .. .. . .. .

S c h e d u l eH: To t a lS a l e so fCampa i g nP r o p e r t y( A t t a c hS c h e d u l eH). .. . .. .. .. .. .. .. .. .. . . .. .. .. .. . .. .

( S c h e d u l eH a p p l i e st oC an d i d a t e s 'Commi t t e e sOn l y )SUB- TOTAL. . . . . .$

SUBTRACTTOTALMONEY SPENTTHI SPERI OD

S c h e d u l eB: Ex p e n d i t u r e st o t a l( A t t a c hS c h e d u l eB ) .. .. .. .. . . . . .. .. .. .. .. .. .. .. .. .. .. .. .. . . . .. .. .. .. ... .. .. . ..

S c h e d u l eF: L o a nRep a y men t st o t a l( A t t a c hS c h e d u l eF ) . . . . . . .. .. .. . . . .. ... .. .. .. .. .. .. . . . . . . .. . ... .. .. ...

CASHON HANDa t t h ee n do f t h i sr e p o r t i n gp e r i o d( i ff i n a lr e p o r t ,b a l a n c em u s tb ez e r o ) ( A t t a c hD R - 3 ).. . . . .. .. . . .. .. .. .. . . . . . .. . . . . .. .. .. .. . . .. .. . . . . . . . . .. .. .. .. .. .. .. .. .. .. .. . . .. . .. . . .. .. .. .. .. .. .. .. .. ... .. $

UNPAI DBI L L S( F r o mS c h e d u l eD - A t t a c hS c h e du l e D ). .. .. .. .. .. . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . . . . .. .. . . .. .. . . . .. .. . . $

I NKI NDCONTRI BUTI ONS( F r o mS c h e d u l eE - A t t a c hS c h e d u l eE ). .. .. . . . . . . .. . . .. .. .. .. .. . . . . . .. .. . . . . . . . . . .. . . .. $

OUTSTANDI NGLOANS( F r o m S c h e d u l eF - A t t a c hS c h e d u l eF ) .. .. . . . .. .. . . . . . . . . . . . . . . . . .. .. .. . . . . . . . . .. . . . . . . . . .. $

CANDI DATECOMMI TTEESONLY:

CONSUL TANTBREAKDOWN ( S c h e d u l eG A t t a c h e d ? )

VALUE OF CAMPAI GNPROPERTY( F r o mS c h e d u l eH - A t t a c hS c h e d u l eH) $

FORM

DR- 2 I DI SCLOSURE

( R e v. 1 1/ 9 7 ) REPORT

F o rO f f i c eUs eOn l yComm. #I n d e x e dA u d i t e dC o mp u t er

L o c a lC ommi t t e e s ,e n t e rD a t eo fE l e c t i o n

C o u n t y&L o c a lC o mmi t t e e s ,e n t e rC o u n t yi nwh i c hE l e c t i o ni sh e l d

5 a 7 F 3 7

YES NO



Fo r I n s t r u c t i o n s ,Se e Ba c k o f F o r m

CONTRI BUTI ONS - -MONEY TAKEN I N( I n c l u d i n gc a n d i d a t e ' sp e r s o n a lf u n d s )

COMMI TT EE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g an i z a t i o n)

s T~. ACANDI DAT NOTE : I FA C NTRI BUTI ONI SRECEI VEDFROMASTATE PAC( P OL I T I C ALACTI ONCOMMI TTEE) ,L I S TTHE PACI DENTI F I CATI ONN BERAND THE PACCHECK NUMER I NTHE DESI GNATEDCOLUMN. A L I S TOF I DNUMBERSI SAVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GNDI SCLOSUREBOARD.

CAUTI ON : Se ct i o n 6 8B . 3 2 A ( 6 ) ,I o wa Code , p r o h i b i t st h e u s e o f i n f o r ma t i o nc o pi e df r o mr e p o r t sand s t a t e me nt s f o r s ol i c i t i n gc o n t r i b u t i oof o ra ny c o mme r c i a l p ur p o s eb y any p e r s o n o t h e rt h an s t a t u t o r yp o l i t i c a lc o mmi t t e e s.

D i s c l o s ur el a wr e q u i r e sc a nd i d a t ec o mmi t t e e st o d i s c l o s et h er e l a t i o n s h i po f a n yr e l a t i v ema ki n g ac o n t r i b u t i o nt o t h e

c o mmi t t e e. Re l a t i o n s h i pmus tb e s h ow n t o t h e t h i r dd e g r e eo fc o n s a n g u i n i t y( b l o o dr e l a t i v e s )a n da 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 )( Se eP a g e 2 o f f o r m sp a c k e t. ). I fs u r n ame o f c o n t r i b u t o ri s t h es ame a s c a n d i d a t e ,b u t t h e r ei s n o

f a mi l i a lr e l a t i o n s h i p ,e n t e r" n o ta 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 pc o l umn.P a g e ~- o f

( f o rSc h e d u l eA)

SCHEDULE

A MONETARY( Re v . 0 2 1 9 6 ) RECE I PT

Q/ CHECK THI SBOX IAMENDI NG FORM

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNTRECE I VED ( i ta p p l i c a b l e ) TO CANDI DATE ' RECEI VED

( MM/ DD/ YR) AND PAC CHECK ( i fa p p l i c a b l e )NUMBER

I D# _

CK#

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TOTAL( i fl a s tp a g e o f t h i s s c h ed u l e ) "




CONTRI BUTI ONS - - MONEY TAKEN . . .( I n c l u d i n gc a n d i d a t e ' sp e r s o n a lf u n d s )

COMMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g an i z a t i o n)^ V

~ c e

STATECANDI DAT NOTE: I FA CI QNTRI BUTI ONI SRECEI VEDFROMA STATEPAC ( P OL I T I CA LACT I ONCOMMI TTEE) ,L I S TTHE PACI DENT I F I CAT IN BE R AND THE PA CCHECKNUMBER I NTHE DESI GNATEDCOLUMN. AL I S TOF I DNUMBERSI SAVAI LABLEFROMTHE I OWAETHI CSANDCAMPAI GNDI SCLOSUREBOARD .

CAUTI ON : Se ct i o n 6 8B . 3 2 A ( 6 ) ,I o wa Cod e , p r o h i b i t st h e u s e o f i n f o r ma t i o nc op i e d f r o mr e p o r t sa n d s t a t e me nt s f o r s o l i c i t i n gc o n t r i b u t i of o r any c omme r c i a l p u r p o s eby a ny p e r s o n o t h e rt h a ns t a t u t o r yp o l i t i c a lc o mmi t t e e s.

D i s c l o s u r el a wr e q u i r e sc a n d i d a t ec ommi t t e e st od i s c l o s e t h er e l a t i o n s h i po f a n y r e l a t i v emak i ng a c o n t r i b u t i o nt ot h e

c o mmi t t e e. Re l a t i o n s h i pmustb e s h ow n t o t h e t h i r dd e g r e eo f c o n s a n g u i n i t y( b l o o dr 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

ma r r i a g e )( S e eP a g e 2 o f f o r ms p a c k e t. ). I f s u r n a me o f c on t r i b ut o ri s t h es ame a s c a n d i d a t e , b u tt h e r ei s n o P a g e

f a mi l i a lr e l a t i o n s h i p ,e n t e r" n o ta p p l i c a b l e "i n t h er e l a t i o n s h i pc o l umn .

.

( f o rSc h e d u l eA)

SCHEDULE

A MONETARY

( R e v. 0 2 / 9 6 ) RECEI P T

F / CHECK T HI SBOX

AMENDI NG FORM

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNTRECEI VED ( i fa p p l i c a b l e ) TO CANDI DATE ' RECEI VED

( MM/ DDI YR) AND PAC CHECK ( i fa p p l i c a b l e )NUMBER

I D#

6 l Pl o L t J r z c d$

CK# / / ~,

.o3c

I D#

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I D# " I ~ CV C . lr ~~ 2 ~ 1 L i w ~ Af' Y~

717

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I D#2Dx_

CK#

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7/

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I D#~GYo3 f , , i - A

CK#

I P`

~ 333

~ 1~~a ~ , 5v s oI D#

Ar y

CK#

> c . 03 . 5

SUB- TOTAL

TOTAL ( i fl a s tp a g e o f t h i ss c h ed u l e ) -3




CONTRI BUTI ONS - - MONEY TAKEN . .

( I n c l u d i n gc a nd i d a t e ' sp e r s o n a lf u n d s )

COMMI TT EE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g an i z a t i o n)

Di s c l o s u r e l a wr e q u i r e sc a n d i d a t ec o mmi t t e e st o d i s c l o s et h e r e l a t i o n s h i po f a n yr e l a t i v ema ki n g ac o n t r i b u t i o nt o t h ec o mmi t t e e. R e l a t i o n s h i pmus t b e s h ow n t o t h e t h i r dd e g r e eo f c o n s a n g u i n i t y( b l o o dr 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 ym a r r i a g e )( S e ePage 2 o ff o r ms p a c k e t. ). I fs u r n ame o f c o n t r i b u t o ri s t h es ame a s c a n d i d a t e ,b ut t h e r ei s n of a mi l i a lr e l a t i o n s h i p ,e n t e r" n o ta 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 pc o l umn .

SCHEDULE

A MONETARY( R e v. 0 2 / 9 6 )

IRECEI PTS

CHECK THI S BOX IAMENDI NG FORM

STA' ' ECANDI DATE. ~/ NOTE : I FAC~ NTRI BUTI ONI SRECEI VEDFROMA STATE PAC( P OL I T I C ALACTI ON COMMI TTEE). L I S TTHE PAC I DENTI FI CATIONNUMBERANDTHE PACCHECKNUMBER I NTHE DESI GNATEDCOLUMN. A L I S TOF I DNUMBERSI SAVAILABLEFROM THE I OWAETHI CSANDCAMPAI GNDI SCLOSUREBOARD.

CAUTI ON : Se c t i o n6 8B . 3 2 A ( 6 ) ,I o wa Code , p r o h i b i t s t h eu s e o f i n f o r m a t i o nc op i e d f r o mr e p o r t sa nd s t a t e me nt s f o rs o l i c i t i n gc o n t r i b u t i oof o ra ny c omme r c i a l p u r p o s eb y a ny p e r s o n o t h e rt h an s t a t u t o r yp o l i t i c a lc o mmi t t e e s.

P a g e . 3 o f( f o rSc h e d ul 4 A

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNTRECEI VED ( I fa p p l i c a b l e ) TO CANDI DATE' RECEI VED( MM/ DDI YR) AND PAC CHECK ( i fa p p l i c a b l e )

NUMBER

4

J l Ae

I D#O La t l ~. ~ , O . ~ ..

/ l - 5

-t - r1 , ~ a g ,

I D#t9a , ,

CK#

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0 1CK#

; ! 2k 4a i c X ~J Jr ,I D#

I D#

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I D#

CK#r

CK# 1 5 ` 4 11C& ~ Z t

SUB- TOTAL

TOTAL ( i fl a s t p a g e o f t h i s s c h ed u l e ) "3



Fo r I n s t r u c t i o ns , Se e Ba c k o f F o r m

CONTRI BUTI ONS- - MONEYTAKEN. .( I n c l u d i n gc a n d i d a t e ' s p e r s o na l f u n d s )

COMMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g a ni z a t i o n)

SCHEDULE

A MONETARY( Re v. 0 2 / 9 6 )I RECE I PT

CHECK T HI SBOXAMENDI NG FORM

S T F y 1 " ECANDI DATg gNOTE : I FA CI QNTRI BUTI ONI SRECEI VEDFROM ASTATEPAC ( P OL I T I CA LACTI ONCOMMI TTEE) ,L I S TTHEPAC I DENTI FI CATI ONNWBER ANDTHE PACCHECKNUM13ERI NTHE DES I GNATEDCOL UMN AL I S TOF I DNUMBERSI SAVAI LABLEFROM THE I OWAETHI CSANDCAMPAI GNDI SCLOSUREBOARD.

CAUTI ON : Sec t i o n 6 8B. 3 2 A ( 6 ) ,I o wa Co d e, p r o h i b i t s t h eus e o f i n f o r ma t i o nc op i e d f r o mr e p o r t san d s t a t eme nt s f o rs o l i c i t i n gc o n t r i b u t i oof o ra n y c o mme r c i a l p u r p o s eby a n y p e r s o n o t h e rt h an s t a t u t o r yp o l i t i c a lc ommi t t e es.

D i s c l o s u r el a wr e q u i r e sc a n d i d a t ec o mmi t t e e st o d i s c l o s et h er e l a t i o n s h i po fa n y r e l a t i v ema k i n ga c o n t r i b u t i o nt ot h e

c o mmi t t e e. R e l a t i o n s h i pmus tb e s h own t o t h e t h i r dd e g r e eo f c o n s a n g u i n i t y( b l o o dr 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

ma r r i a g e )( S e ePage 2 o f f o r ms p a c k e t. ). I f s u r n ame o f c o n t r i b u t o ri s t h es ame a s c a n d i d a t e ,b u t t h e r ei s n o Page - _ o f

f a mi l i a lr e l a t i o n s h i p ,e n t e r" n o ta p p l i c a b l e "i n t h er e l a t i o n s h i pc o l umn .

( f o rSc h ed u l eA

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNTRECENED ( i fa p p l i c a b l e ) TO CANDI DATE' RECEI VED

( MM/ DDI YR) AND PAC CHECK ( i fa p p l i c a b l e )NUMBER

I D# l p p ~ 7

C K#

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17 0 7 $

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TOTAL ( I fl a s t page o f t h i ss c h e d ul e )$ 5~



THI SBOX APPLI ESTO CANDI DATES' COMMI TTEES ONLY :

Pu r c h a s e s o f c e r t a i nc a mp a i g np r o p e r t y c o s t i n g$ 5 0 0 o r mo r e mus t a l s ob e i n v e n t o r i e do n Sc h e d u l eH. ( R e f e rt oSc h e d u l eH i n s t r u c t i o n s. )

Ex p e n d i t u r e st o p e r s o n s / e n t i t i e sp r o v i d i n gc o n s u l t i n g , a dv 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 smus t a l s ob e d e t a i li t e m i z e do nSc h e d ul eG b y t h eamou n t ,p u r p o s e ,a n d d a t eo fe a c h t y p eo f e x p e n d i t u r emad e b y t h ep e r s o N e n t i t yo n b e h a l fo ft h ec a n d i d a t e ' sc o mmi t t e e. ( R e f e rt oSc h e d u l eG i ns t r u c t i o n sa n d I o waCo de 5 6. 6 ( 3 ) ( 1 ). )

( f o rSc h e d u l eB )

POH I NSIRUCTI ONS,SEE BACK OF FORM SCHEDULE

EXPENDI TURES B- - MONEY SPENT FROM COMMI TTEE ACCOUNT MONETARY( Re v. 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE: FORCONTRI BUTI ONSMADE TO STATEWI DEOR LEGI SLATI VECANDI DATES,L I S TTHE CANDI DATEI DENTI FI CATI ONNUMBER I NTHEDESI GNATEDCOLUMN AND THE CHECK THI S BOX I FPAC CHECK NUMBER FOR EACHEXPENDI TURE. A L I S TOF I DNUMBERS I SAVAI LABLEFROM THE I OWA AMENDI NG FORMETHI CS& CAMPAI GNDI SCLOSUREBOARD .

COMMI TTEE NAME ( Mu s t b e s am e a s o n St a t e me n to fOr g a n i z a t i o n )

~ ) l , r G ' r l ! ~

CANDI DNUMBER

41E NAME AND ADDRESS O WHOM PURPOSE AMOUNT1 ; DATE I D EXPENDI TURE ( DESCRI BETRANSACTI ON) EXPENDED

EXPENDED ( i fa 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 PAC

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ID#NUMBER

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TOTAL ( i fl a s tp a g e o f t h i ss c h e du l e ) $



THI SBOX APPLI ESTO CANDI DATES' COMMI TTEES ONLY :

Pu r c h a s e s o f c e r t a i nc a mp a i g np r o p e r t yc o s t i n g$ 5 0 0 o rmo r emus t a l s ob e i n v e n t o r i e do n Sc h e d u l eH. ( R e f e rt oSc h e d u l eH i n s t r u c t i o n s. )

Ex p e n d i t u r e st o p e r s o n s / e n t i t i e sp r o v i d i n gc o n s u l t i n g ,a dv 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 gs e r v i c e smus t a l s ob e d e t a i li t e mi z e do nSc h e d u l eG b y t h eamou n t ,p u r p o s e ,a n d d a t eo f e a c h t y p eo f e x p e n d i t u r emad e b y t h ep e r s o n / e n t i t yo n b e h a l fo f t h ec a n d i d a t e ' sc o mmi t t e e. ( R e f e rt o

Sc h e d u l eG I n s t r u c t i o n sa n d I o waCod e 5 6. 6 ( 3 ) ( i ). )

( f o rSc h e d u l eB)

FOR I NSTRUCTI ONS,SEE BACK OF FORM SCHEDULE

EXPENDI TURES B MONETARY- - MONEYSPENTFROMCOMMI TTEEACCOUNT ( Re v. 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE: FORCONTRI BUTI ONSMADE TOSTATEWI DEOR LEGI SLATI VECANDI DATES,L I S TTHE CANDI DATEI DENTI F I CATI ONNUMBER I NTHEDESI GNATEDCOLUMN AND THE F0 7 CHECK THI S BOX I FPAC CHECK NUMBER FOR EACHEXPENDI TURE. AL I S TOF I DNUMBERS I SAVAI LABLEFROM THE I OWA AMENDI NG FORMETHI CS&CAMPAI GN DI SCLOSUREBOARD .

CO I T TEENAME ( 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 )

7 1

v

ANDI DATE% NAME AND ADDRESS TO WHOM PURPOSE AMOUNT~~DATE I DNUMBER EXPENDI TURE ( DESCRI BETRANSACTI ON) EXPENDEDEXPENDED ( i fa 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 PAC

CHECKNUMBER

I D# Br e r r WVi r t

0

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i c , - 7 -0I D#

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vw v 1 / 7 e ~r ~

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CK# / C - l opl ~ 1 ~ p f 7

SUB- TOTAL

TOTAL ( i fl a s tp a g e o f t h i ss c h e du l e )



THI SBOX APPLI ES TO CANDI DATES' COMMI TTEES ONL Y :

Pu r c h a s e so f c e r t a i nc a mp a i g np r o p e r t yc o s t i n g$ 5 0 0 o r mo r e mus t a l s ob e i n v e n t o r i e do n Sc h e d u l eH. ( R e f e rt o Sc h e d u l eH i n s t r u c t i o n s. )

Ex p e n d i t u r e st o p e r s o n s l e n t i f e sp r o v i d i n g c o n s u l t i n g , a dv 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 smus t a l s ob e d e t a i li t e m i z e do nSc h e d u l eG b y t h eamou n t ,p u r p o s e ,a n d d a t eo f e a c h t y p eo f e x p e n d i t u r emad e b y t h ep e r s o N e n t i t yo n b e h a l fo f t h ec a n d i d a t e ' sc o mmi t t e e. ( R e f e rt oSc h e d u l eG i n s t r u c t i o n sa n d I o waCode 5 6 . 6 ( 3 ) ( i ). )

( f o rSc h e d u l eB )

FOR I NSTRUCTI ONS,SEE BACK OF FOr f M SCHEDUL E

EXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT

( Re v. 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FORCONTRI BUTI ONSMADE TOSTATEWI DEOR LEGI SLAT I VECANDI DATES,L I STTHE CANDI DATEI DENTI F I CATI ONNUMBER I NTHEDESI GNATEDCOLUMN AND THE O CHECK THI S BOX I FPACCHECKNUMBER FOR EACHEXPENDI TURE. AL I S TOF I DNUMBERSI SAVAI LABLEFROM THE I OWA AMENDI NG FORMETHI CS&CAMPAI GNDI SCLOSUREBOARD .

C MI TTEE NAME ( Mu s t b es am e a s o n St a t eme n to f O r g a n i z a t i o n )N

, ~ ~NDI DATE NAME ANu ADDRESS TO WHOM PURPOSE AMOUNTDATE 1 t b NUMBER EXPENDI TURE ( DESCRI BETRANSACTI ON) EXPENDED

EXPENDED ( i fa 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 PAC

CHECKNUMBE R

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SUB- TOTAL $

TOTAL ( i fl a s tp a g e o f t h i ss c h ed u l e ) $

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