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  • 8/7/2019 Terry Michael__1332__scanned

    1/8

    FOR .; ` ~ , I S TRUCT I ONS. SEE BACK OF FORM

    DI SCLOSURESUMMARY PAGE

    COMMI TT EE NAME ( Mu s tb e s ame a s o nSt a t eme n t o f O r g a n i z a t i o n )V l

    ,5; 1 nb 0 vs 4o V - Y 1r 1Ic 1 1 WITe r r ! /

    I MPORTANT: I n d i c a t et y p eo fc o mmi t t e ey o ua r er e p o r t i n gf o r: Lo

    ( 1 ) 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 an 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 ommi 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( 8 ) S u p p o r tS l a t eo fC an d i d a t e s

    SI GNATURE OF TREASURER ( o rp e r s o n f i l i n gt h i sr e p o r t )5 / s - Z&R - 3 9 1 4 2

    Ro u t i n eP e n a l t i e sDu e Fo rL a t eF i l e dR e p o r t sRange f r o m$ 2 0t o $ 8 0 0

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

    I AM F I L I NGA 3- AnuaY' h Z ZZ i - ) ,PQ - - SPO RT FOR AN/ A( 1 )ELECTI ON/ ( 2 ) NON- ELECT I ONYEAR .( r e p o r td a t e )

    CHECK I FAMENDMENT TO REPORT DATED

    [ ] Check i ft h i si s f i n a l( t e r mi n a t i o n ) r e p o r tan d a t t a c h No t i c eo f D i s s o l u t i o nF or mDR- 3.( Yo umust c o n t i n u et o f i l er e p o r t su n t i la N o t i c eo f D i s s o l u t i o ni s f i l e d. )

    STATEMENTOF CASHON HAND

    I n d i c a t eon e

    CASH ON HAND a t t h ee n d o ft 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 nc emu s tb e z e r o ) ( A t t a c hDR- 3) . .. .. .. .. . .. . . .. . . ... . .. . .. .. .. . . .. ... .. .. . . . . . . . . . .. . . .. . .. ... .. . .. .. . . . . . . . .. . .. . . . . .. . . .. ... .. .. ... .. ..$

    FORM

    DR- 2 I DI SCLOSURE( R e v. 0 1 / 9 8 ) REPORT

    Fo rO f f i c eUs e On l y iComm. #

    r

    I n d e x e d _

    A u d i t e d

    C o mp u t e rLL/ - V u v

    TELEPHONE DATE S I GNED

    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 ommi 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 s h e l d

    CASH ON HAND a t t h eb e g i n n i n go ft h e r e p o r t i n gp e r i o d. ( T h i si s t h et o t a lo f a l lmon i e s h e l db y t h ec ommi t t e e. T h i samount MUST b e t h es ame a s t h ec a s h o n hand a t t h ee n d o f t h el a s tr e p or t i n g p e r i o d ,o r mu s t b ez e r oi ft h i si sf i r s tr e p o r tf i l e d. 0

    ADD TOTAL MONEY TAKEN I NTHI SPERI OD

    Sc h e d u l eA : Cash C o n t r i b u t i o n st o t a l( A t t a c hSc h e d u l eA) .. . . . . . . .. . . . .. .. .. . . .. . . . .. . . . .. .. .. . . . .. .. . . . . .5 7 0 7 0 . dO

    Sc h e d u l e F: L o a n s Re c e i v e dt o t a l( A t t a c hSc h e d u l e F ). .. ... .. .. . . .. .. . . . . . . . . . .. . . . .. .. ... .. . . . . . .. .. .. . . . . . C) . OU

    Sc h e d u l e H: T o t a lSa l e s o fCampa i g n P r o p e r t y( A t t a c hSc h e d u l eH) . . . .. .. . . . .. ... .. .. .. . . . . . .. . . . . . 0- 00

    ( Sc he d u l eH a p p l i e s t oCa n d i d a t e s ' Commi t t e e sOn l y )

    SUB- TOTAL . .. .. $

    SUBTRACT TOTAL MONEY SPENT THI S PERI OD

    Sc h e d u l e B: E x p e n d i t u r e st o t a l( A t t a c hSc h e d u l eB ) . . . .. . .. .. .. .. . . . . . . . . . . . . . . . . .. .. .. . . . . . . . . . . .. .. .. ... .. ..

    Sc h e d u l e F : Loan Rep ay men t s t o t a l( A t t a c hSc h e d ul eF ) .. .. . .. . .. . . . .. . . . .. . .. . .. .. . . . .. . . .. . . . .. .. . .. .. ..

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    UNPAI DBI L L S( F r o mSc h e d u l eD - A t t a c hSc h e d u l eD) . .. . .. .. .. .. .. . . . .. .. .. . . . . .. . . . . . .. . . .. . . . .. . . . .. . . . . .. . . . .. .. . . .. $

    I NK I NDCONTRI BUTI ONS ( F r o mSc h e du l eE - A t t a c hSc h e d u l eE). .. .. .. .. .. . .. .. .. .. .. . . . .. . . . .. .. .. .. . . ... .. .. .. $

    OUTSTANDI NG LOANS ( F r o mSc h e d u l e F - A t t a c hSc h e d u l eF ) . . . .. .. .. . . .. .. . .. .. .. . . . . .. . .. . . . .. .. .. .. .. . .. .. . . . .$

    CANDI DATE COMMI TTEES ONLY :

    CONSULTANT BREAKDOWN ( Sc h e du l eG A t t a c h e d ? ) YES \ N J NO

    VALUE OF CAMPAI GN PROPERTY ( F r o mSc h e d u l e H - A t t a c hSc h e d ul eH) $

  • 8/7/2019 Terry Michael__1332__scanned

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    Fo r I n s t r u c t i o n s ,Se e Ba c k o f Fo 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 TTEE NAME ( Mu s tb e s ame a s o nS t a t eme n t o fOr g a n i z a t i o n )

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    SCHEDULE

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    CAUTI ON: S e c t i o n6 8 B. 3 2 A ( 6 ) ,I o waC o d e ,p r o h i b i t st h eu s e o f i n f o r m a t i o nc o p i e df r o mr e p o r t sa n d s t a t e m e n t sf o rs o l i c i t i n gc o n t r i b u t i o no r

    f o ra n yc o mme r c i a l p u r p o s eb ya n yp e r s o no 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.

    0 0 10

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

    SUB- TOTAL3 5

    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 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 yr e l a t i v em a l t 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 pmu s t b es h o w nt ot h et 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 da 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 e2 o ff o r m sp a c k e t. ). I fs u r n ameo f c o n t r i b u t o ri st h es ame a s c a n d i d a t e ,b u tt h e r ei sn o Page o f

    f a m i 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 nt h er e l a t i o n s h i pc o l u mn.( f o rS c h e d u l eA )

    DATERECEI VED

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  • 8/7/2019 Terry Michael__1332__scanned

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    Fo r I r i s t i r u c t i o n s ,Se e Back of Fo 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 ' s p e r s o na lf u n d s )

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

    Y) Ql shbor s - Gov l m* 1 c. Yl o e ! - r e i ^ r , J 1

    STATECANDI DATESNOTE : I FACONTRI BUTI ONI SRECEI VEDFROMASTATE PAC( P OL I T I CA LACTI ON COMMI TTEE) ,L I S TTHE PACI D EN TI F I C AT I ONUMBER ANDTHE PACCHECK NUMBERI NTHE DESI GNATEDCOLUMN. AL I S TOF I DNUMBERSI SAVAI LABLEFROMTHE 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 st h e u s e o f i n f o r m a t i o nc op i e df r o m r e p o r t san 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 o no rf o r an y c omme r c i a l p u r p o s e by an 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 .

    SUB- TOTAL

    TOTAL ( i fl a s tpage o f t h i s .70s c h e d ul e ) $

    Di 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 fan 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 ec o mmi t t e e. Re l a t i o ns h i pmustb e s h own t o t h et 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 da f f i n i t y( r e l a t i v e sb yma r r i a g e )( S e eP a g e 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 u t t h e r ei sn o P a g e o ff a m i l i a lr e l a t i o n sh 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 e A)

    SCHEDULE

    A MONETARY( Re v. 0 6 / 9 7 ) RECEI PTS

    CHECK THI SBOX I FAMENDI NG FORM

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

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    THI S BOX APPLI ESTO CANDI DATES' COMMI TTEES ONLY :

    Pu r c h a s e s o fc 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 4 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 / 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 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 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 n

    Sc 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 i 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 et

    Sc 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,SE E BACK OF FORM SCHEDULE

    B MONETARYEXPENDI TURES- MONEY SPENT FROM COMMI TTEE ACCOUNT ( Re v. 0 9 1 9 7 ) EXPENDI TURES

    STATE PAC COMMI TTEES : NOTE: FOR CONTRI BUTI ONSMADE TO STATEWI DEOR LEGI SLATI VE CHECK THI S BOX I FCANDI DATES,L I S TTHE CANDI DATEI DENTI F I CATI ONNUMBER I NTHE DESI GNATEDCOLUMN AND THEPAC CHECK NUMBER FOR EACHEXPENDI TURE. A L I STOF I DNUMBERS I SAVAI LABLEFROM THE I OWA AMENDI NG FORMETHI CS&CAMPAI GNDI SCLOSUREBOARD .

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  • 8/7/2019 Terry Michael__1332__scanned

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    T HI SBOX APPL I ESTO CANDI DATES'COMMI T T EESONLY :

    P u r c h a s e so fc 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 0o rmo r emu s ta l s ob e i n v e n t o r i e do nS c he d u l eH. ( R e f e rt oS c he d u l eH i n s t r u c t i o n s. )

    E x pe 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 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 gs e r v i c e smu s ta l s ob ed e t a i li t e m i z e do nS c h e d u l eG b yt h ea mo u n t ,p u r p o s e ,a n dd a t eo f e a c ht y p eo f e x p e n d i t u r emade b yt h ep e r s o n / e n t i t yo n b e h al fo ft h ec a n d i d a t e ' sc o mmi t t e e. ( R e f e rt oS c h e d u l eG i n s t r u c t i o n sa n dI o w aCo d e 5 6. 6 ( 3 ) ( 1 ). )

    ( f o rS c h e d u l eB )

    FOR I NSTRUCTI ONS,SEE BACK OF FORM SCHEDULE

    EXPENDI TURES B MONET ARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT ( R e v. 0 9 / 9 7 ) EXPENDI TURESTATEPAC COMMI T T EES: NOTE: FORCONTRI BUTI ONSMADETO STATEWI DEOR L E GI S L ATI V ECANDI DATES,L I S TTHECANDI DATEI DE NT I F I CATI ONNUMBERI NTHEDESI GNATEDCOLUMNAND THE E CHECK T HI SBOX I FPACCHECK NUMBERFOR EACHEXPENDI TURE. A L I S TOF I DNUMBERSI SAVAI LABLEFROMTHEI OWA AMENDI NG FORMETHI CS &CAMPAI GNDI SCLOSUREBOARD.

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    FOR I NSTRUCTI ONS,SEE BACK OF FORM SCHEDULE

    EXPENDI TURES B MONETARY- - MONEY SPENTFROM COMMI TT EEACCOUNT ( Re v. 0 9 / 9 7 ) EXPENDI TURESSTATE PAC COMMI TTEES : NOTE: FOR CONTRI BUTI ONSMADE TO STATEWI DEOR LEGI SLAT I VECANDI DATES,L I S TTHE CANDI DATEI DENTI F I CATI ONNUMBER I NTHEDESI GNATEDCOLUMN AND THE CHECK THI SBOX I FPAC CHECK NUMBER FOR EACHEXPENDI TURE. AL I STOF I DNUMBERS I SAVAI LABLEFROM THE I OWA AMENDI NG FORMETHI CS&CAMPAI GNDI SCLOSUREBOARD .

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    e ) ~nhon "-o v Ni Cx We ` ' T q -r YCANDI DATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNT

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    ' F ORI NSTRUCTI ONS,SEE BACK OF FORM

    COMMI TT EE NAME ( M u s tb e s ame a s o n S t a t e me n to fO r g a n i z a t i o n )

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