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

CONTRI BUTI 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 TTE

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 n i z a t i o n)

STATE CANDI DATES NOTE : 4 F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) . L I S T THE PAC I D E N T I F I C A T I O NNUMBER 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 Co d e , 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 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 rf o r a ny c omme r c i a l p ur p o s e b y a ny 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 .

SCHEDULE

A MONETARY

( R e v . 0 6 / 9 7 ) RECEI PTS

CHECK T HI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT J I F FOR

RECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SER

NUMBER I NCOME

I D #/ ' f e ~2 mA1 t J t t c f ~r h - dy ~~~

CK# l DOa . . lA22C~ G~~~ l e

S-Do ~i ~

I o # L

CK# / ooa ' ~ ~ ~ e e t r G~r ZGf e r - -~c

- t )

/ " t r 1 n D-D6 ., r I D#- ZRV / ' r l . 6 . J ~ o s k e c . - r v

i. , I D#

e r l l o d i Av d o h u o o i r 0 l c L

CK# , 3 Df hnQi N J !; ~ - ~l l o

I D # Ge 0 " - f R e l - 0 . wCK# 1 Cf / 5 / Gud. 9 / e Av e -

, tI D #

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

CONTRI BUTI 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 TT EE 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 )

STATE CANDI DATES N4 I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I D E N T I F I C AT I O NNUMBER 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 ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .

CAUTI ON : Se c t i o n 68 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 m a t i o n c op 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 rf o r a ny c omme r c i a l p u r p o se b y a n y p er 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 .

SCHEDULE

A MONETARY

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

[ ] CHECK T HI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT J I F FOR

RECE I VED( i f a p p l i c a b l e )

TOCANDI DATE'

RECE I VED FUND-( MM/ DD/ YR ) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOME

I D# Tbee?_T k ' en . k 5 j e c k

I D#

CK# t a. 3 4 , 9 1 ' s c o r n s n , l 9 v - e -l I S

l r I D#oR

Y a C e ~ n T l , ) ~mo o . P ~ t ` i c r Cc n T i . ~ Ca s . 1

CK# / oZa t ox 5 7 o _ C )

5 o - r ~` t I D# d ( o v ~ L o c ~ l r ' ! G e h , m~ 7 7 c e r ~ e t l ~ a~ T c , q ~ l ~ l i

CK#/ f i r - 1 . - Gr p ~~ad

Y 3 6I D# e , S Lo~ n , E~ -~ jd3 t 7

CK#

I D#

CK#

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FOR I NS TRUCT I ONS , SEEBACK OF FORM SCHEDULE

EXPENDI T URES B- - MONEY SPENT FROM COMMI T T EE ACCOUNTMONET ARY

( R e v . 0 9 / 9 7 ) EXPENDI TURES

S TA TE PAC COMMI TT EES : NOTE : FORCONTRI BUTI ONS MADE TO STATEWI DE OR L E G I S L A T I V ECANDI DATES, L I S T T HE CANDI DATE I D E N T I F I C A T I O N NUMBER I N THE DES I GNATED COLUMN ANDTHE CHECK T HI S BOX I FPAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S A VA I L A B L E FROM THE I OWA AMENDI NG FORMET HI CS & CAMPAI GN DI SCLOSURE BOARD .

COM EE NAME ( Mu s t b e s a m e 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 )

uANDI DATE/ / NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBED( ' EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e me n t ) WAS MADE( MM/ D D/ Y R) AND PAC

CHECKNUMBER

I D # /Cs 9 f e T e t e I ~ r 9 2 t n T l ; ? ~ ' 1 6 4 t : 5 « e C 9 , - ' a s) 73` 1 &A. a nd A . ,

s sCK#~ /

°Pe 5 e iI D # `

CK#

I D #

CK#

I D #

CK#

I D #

CK#

I D #

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FOR I NSTRUCT I ONS , SE E BACK OF FORM

COMMI TT EE NAME( Mus t b e s ame 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 )

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

o c ~TOTAL UNPA I D LOANS FROMLAST REPORT I NG PER I OD $

( : ~ r

PART - MONET ARY LOANS RECEI VED T HI S REPORT I NG PER I 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 , must b e s h ow n i f a t h i r d p a r t y i s

i 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 ( PART 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 m m i 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

m a k i n g a c o n t r i b u t i o n t o t h e c o m m i 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 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 ma r r i a g e ) I f s u r n ame 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 m n when i t a p p l i e s

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

TOTAL CASH REPAYMENTS ( PART I I )

$

F r o m Sc h e d u l e E - T OT AL LOANS FORGI VEN

$

TOTAL OUTSTAND I NG LOANS END OF REPORT PER I OD

$

Page - ~ o f

( f o r S c h e d ul e )

SCHEDULE

F LOANS

( R e v 0 7 / 0 3 ) RECEI VED& REPA I D

[ ] CHECK T HI S BOX I F

AMENDI NG FORM

DATE P AI D( MM/ DD/ YR)

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 ONSH I PTO CANDI DATE'

I f A l i c a b l e

AMOUNT

REPA I D

DATERECEI VEDMMI DDI YR

NAME A ND ADDRESS O F 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 DA TE

I f A p p l i c a b l e * )

AMOUNTOF L OA N

$