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FOR I NSTRUCTI ONS, SEE BACK OF FORMDI SCLOSURE SUMMARY PAGE

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 a N n > ~ P _ ) erg L t - Y 1 ' 1I MPORTANT : I n d i c a t e b y # t y p r 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 :( ) S t t e t v l d e ! L e g i M n l l v e / J u d g e S t a n d i n g f o r R e t e n t i o n C a n d i d a t e ( 2 ) S t a t ( , , PAC ( 3 ) S t a t e P a r t y( 4 ) C o u n t y C e n t r a l Co mmi t t e e ( 5 ) C o u n t y Can ~ d a t e ( 6 ) C i t y C a n d i d a t e ( 7 ) S c h o o l B o a r d o r O t h e r P o l i t i c a lS u b d i v i s i o n C a n d i d a t e ( t o ) C o u n t y PAC ( 9 ).C. 4 4 PAC- ( , a ~ , ) . ~ c h o o l B o a r d o r Ot h e r P o l i t i c a l S u b d i v i s i o n PAC( 1 ? ) L o c a ! B a l l o t I s s u eCANDI DATE COMMI TTEES ONLY:Ca nd i d a t e NameLYSJL~nXC,I _ ` f 4 L h ' Y YI 4 - l a a - . Vt / 1 , e i o l . l . l nJ te_J f f c e So u g h t

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t i c a l P a r t y ( i f a p p l i c a b l e )

L a t e 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 . P u r s u a n t t o I o wa Code s e c t i o n 6 8 6 . 3 2 A ( 7 )t h e c a n d i d a t e , f o r a c a n d i d a t e ' s c o mm i t t e e , a n d t h e c h a i r p e r s o n , f o r a n y o t h e r t y p e o f c o mm i t t e e , 1 2 t h eI n d i v i d u a l r e s p o n s i b l e f o r f i l i n g t i m e l y a n d a c c u r a t e r e p o r t s .

( r e p o r t d a l e ) I n d i c a t e b y #OCHECK I F AMENDMENT TO REPORT DATED

Ch e c k i f t h i s . t 1 n a l ( t e r m i n a t i o n ) r e p o r t an 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 o r m DR- 3 .( Y ou must c o nt i n ue t o f i l e r e p o r t s u n t i l a DR- 3 i s f i l e d . )

STATEMENT OF CASHON HAND

REPORT FOR ( 1 ) ELECTI ON / ( 2 ) NON- EL ECT I ON YEAR .

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 o t a l o f a l l f u n d s h e l d b y t h ec o mmi t t e e T h i s amoun t MUST b e t h e same a s t h e c a s h o n h a n d a t t h e e n d ~roo f t h e l a - a t r e p o r t i n g p e r i o d o r must 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 . ) . , . . . . . . . . . . . . . . . . . . . . . . . . .

" ' UNPAI D BI L L S ( F r o m Sc h e d u l e D - A t t a c h Sc h e d u l e D) _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g' I N K I ND CONTRI BUTI ONS ( F r o m Sc h e du l e E - A t t a c h Sc h e d u l e E ) . . . . , . . . . . . . , . . . . . . . . . . . . . , . . . . . . . , . . . . . . $

S TATE COMMI TTEES : Submi t a r e c o n c i l e d c a mp a i g n a c c o u n t b a n k s t a t e me n t i n J a n u ar y o f e a c h y e a r

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F i l e w i t h :I o wa E t h i c s an d Campa i g nD i s c l o s u r e B oa r d5 1 0 E . 1 2 ' " , S t e . 1 ADe s M o i n e s , I o w a 5 0 3 1 9F a x : 5 1 5 - 2 8 1 - 3 7 0 1

DATE SI GNED

L o c a l C o mmi t t e e s , e n t e r D a t e o f C l e c t i o r

Co u n t y 3 L o c a l C o mmi t t e e s , e n t e r C o u n t y nv l h i c h C l ( ) c t l o n i 5 h e l d

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. ' 6ADD TOTAL MONEY~TAKE I N T HI S PERI OD~ l v c k C" o h & : o rSc h e d u l e A : 6 t r s t r t o t a l ( A t t a c h Sc 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 ) . . . . . . . . . at e D 0Sc h e d u l e F : L o a n s Re c e i v e d t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d u l e H : T o t a l Sa l e s o f Camp a i g n P r o p e r t y ( A t t a c h Sc h e d u l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( Sc h e Oml e H- a p ol i e s t o Ca n d i d a t e s ' Comm g e e s On t y )SUB- TOTAL . . . . . . . . . . . . . S

SUBTRACT TOTAL MONEY SPENT T HI S PERI ODSc h e d u l e E Ex p e nd i t u r e s t o t a l ( A t t a c h Sc h e d u l e E ) ( " a l s o s e e d e bt s an d l o a n s b e l o w) . . . , . . . . . . aS9 0Sc h e d u l e F L o a n Re pa y me n t s t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . , . . . . . . . . . . . . . . . . . . . . , . . . . . . . .

CASH ON HAND a t t h e e n 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 al a nc e mustb e z e r o ) ( A t t a c h DR- 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

" OUTSTANDI NG LOANS ( F r o m Sc h ed u l e F - At t ac h Sc h e d u l e F ) . , . . . , , , . . . , . . , . , . . . . . , . . . , . . . . . $CONSULTANT BREAKDOWN ( Sc h e du l e G A t t a c h e d? ) YESCA_ D I DATE COMMI TTEES_ONLY :VALUE OF CAMPAI GN PROPERTY ( F r o m Sc h e d u l e H - A t t a c h Sc h e d u l e H ) $

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1 6 : C, ~ i ' J r ~ t 3 6 1 2 1 - 5 6 3 - - - 8 T - 4 ~ ~ 8 3 L - J I P J t - r 0 HI J D I T ORFo r I n s t r u c t i on s , See Back o f Fo r mCONTRI BUTI ONS - - MONEY TAKEN I N

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SUB- TOTAL

TOTAL ( i f l a s t page o f t h i s s c h e du l e )Di s u on u r e l 9 v . r e q u i r e s c a n di d a t e c o mml l l e e s t o d i ^ Go r e t h e r e l a t i o n s h i p o f a n y r e l e l i v e mgk. l n p 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 l o n ; h i p m u s t be s h o wn t o t h e t h i r d d e g r e e o f c on s an gu 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 byma r r i n g e) I f su r name o f c o n t r i b u t o r i s t h e s ame a s c a nd i d a t e , bu t t h er e I s n o P a g ef 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 pp 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 .

o f-( f o r Sc h e d u l e A)

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT t i I F FRECEI VED ( i f a pp l i c a b l e ) TO CANDI DATE' RECEI VED FUND( MM/ D D/ YR ) ANDPAC CHECK ( i f a pp l i c a bl e ) RAI SE

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T HI S BOX A PP L I E S TO CANDI DATES ' COMMMEE3 ONL Y .

: o I f I f J I ; D HUD I TOR P ~ ~ : a E ~

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 - - f l o g ; 5 00 o r mo r e mu s t n l g o b e I n v e n t o r i e d o n S c he 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 . )E x p e n d i t u r e s t o p e r s o n s l o 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 m u s t a l s o b e d e t a i l I t e m i z e

1 io n

Sc h e d u l e G b y t h e a mo u n t , p u r p o s e , a n d d a l e o f e a c h t y p e o f e x p e n d i t u r e m a d e b y 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 n d i d a t e ' s c o mmi t t e e . ( R e f e r t oS c h e d u l e G I n s t r u r - t i o n n a n d l o w -, 4 Cod e 0 8 A , 4 0 2 ( 3 ) ( I ) . ) - _P a g e o f

( f o r Sc h e du l e 6 )

FORWSTRUCTI ONS, SEE BA CP O i l ~ FORM SCHEDULEEXPENDI T URES B MONET ARY- - MONEY SPENT FROMCOMMI TTEE ACCOUNT ( Re v . 0 7 1 0 3 ) EXPEND I TURES

S T AT E P AC COMMI TTEES : NOT E : F OI 2 CONTRI BUT I ONS MADE T O STAT EWI DE OR L EGI S L AT I V ECANDI DATES, L I S T 7 1 4 E CANDI DATE I DENT I F I CA TI ON NUMBER I N T HE DES I GNATED COLUMN AND T HE CHECK T HI S BOX I FP AC CHECK NUMBER F OR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVA I LABLEF ROM T HE I OWA AMENDI NG FORMETHI CS 0 , CAMPA I GN D I SCLOSURE BOARD .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 n i z a t i o n )

CAND I DATE NAME AND ADDRESS T O WHOM PURPOSE AMOUNTDATE I D NUMBER EXPEND I TURE ( DE SCRI BE TRANSACT I ON ) EXPENDEDEXPENDED ( I f a p p l i c a b l e ) ( D i s b u r s o m e n ( ) WAS MADE( h 1 M/ DD/ Y R) AND PACCHECKNUMBER

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FOR I NSTRUCTI ONS, SEE BACK OF FORMEXPENDI TURES - - MONEYSPENT FROMCOMMI TTEE ACCOUNT

STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI S LAT I VECANDI DATES, L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COI , U h AN AND THEPAC C I I E CK NUMBER FOR EACH EXPENDI TURE A L I S T OF I D NUMBERS I S AVAI LABLEFROM THE I OWAETHI C,S& CM. 1 P A I G N DI SCLOSURE BOARD

T HI S BOX APP L I ES TO CANDI DATES' COMMI TTEES ONLY :

SCHEDULE0E( R e v . 0 7 1 0 3 )

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MONETARYEXPENDI TURESOCHECK T HI S BOX. I F

AMENDI NG FORM

E x p e n d i t u r e s t o p e r s o n , / 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 mu s t o f - s o b e d e t a i l i t e m i z e d o nSc h e d u l e G b y t h e a m o u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e m a d e b y t h e p e r s o n l o n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o mmi t t e e ( R e f e " t oS c he d u l e G i n s t r u c t i o n s a n d I o w a Co d e 6 B A A 0 2 ( 3 ) ( i ) . )

( f o r S c he d u l e R )

COMMI TTEE NAME ( Mu s t b e s a m e a s o n St a t e me n t o f O r g a n i z a t i o n )

CANDI DATE NAME ANDADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( d a p p l i c a b l e ) ( D i s b u r r e mo n t ) WAS MADE( MMI DDI YR) AND PACCHECK ~L~ CXPENSt S PAt o O GANDI DATENUMBERI D#

1 ~ S P - ` ~ P0 - 4 Ca - r ^ J Sa o o c K# $ , 79 , 0 , 00d 4 p r I ' I I D p a s + c ~ - Y ~ ' ~ s 540-00a o 0 6 cK# l , ~ S ~S~ e - ~ - ~ ~r u J ~' n ^ ~< S SI 9 1 ' 1 S ~Dj " 93A P r ; I I D# Spr i ng 1 6 r o v e 4eYQ l d i 4 - ~ 1 S ~ ' o ' r r n - I , Z QA00 CK# Ic o S ~~ o r Pe T , m o t J 5 . , - 0 1 a 1 0 0

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