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FORI NSTRUCT I ONS, SEEBACK OF FORMDISCLOSURESUMMARYPAGE
COMMI TT EE NAME ( M u s t b e same a s o n St a t e me nt o f O r g a n i z a t i o n )~ r i c l t 'I MPORTANT : I n d i c a t e t y p e o f c o mm i t t e e y o u a r e r e p o r t i n g f o r : a( 1 ) S t a t e w i d e / t _ e g i s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e( 5 ) C o u n t y PA C ( o " ) B a l l o t I s s u e / F r a n c h i s e C o mm i t t e e ( 7 ) C o u n t y / C i t y C e n t r a l C o mm i t t e e( 8 ) S u p p o r t S l a t e o f C a n d i d a t e s
SI GNATURE OF TREASURER ( o r p e r s o n f i l i n g t h i s r e p o r t )
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Chec k i f t h i s i s f i 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 rm DR- 3 .
C o u n t y & L o c a l C o mm i t t e e s , e n t e r C o u n t y i n( Y o u m u s t c o n t i n u e t o f i l e r e p o r t s u n t i l a N o t i c e o f D i s s o l u t i o n i s f i l e d . )
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STATEMENT OF CASH' ONHANDCASH 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 h i s i s t h e t o t a l o f a l l mon i e s h e l db y t h e c o mm i t t e e . Th i s amou n t MUST b e t h e same a s t h e . c a s h o n han d a t t h e en do f t h e l a s t r e p o r t i n g p e r i o d , o r mu s t be 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 . ) . . . . : . . . . . . . . . . . . . . . . . . . . . . . . $
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F o r I ~ s t r u c t i o n s , - S e e Back o f F o r mCONTRI BUTI ONS - - MONEYTAKENI 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 be s ame a s o n St a t e me n t o f Or g ani z a t i o n)
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Fo r I n s t r u c t i on s , Se e Back o f Fo r mCONTRI BUTI ONS - - MONEYTAKEN 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 TTEE NAME ( Mu s t b e s ame as o n S t a t e me n t o f O r g a n i z a t i o n )D"Y) i S ~- o r , 1 . - o wa- t j f a~e _/-l o u s e - S T A T E CANDI DATES NOTE : I F A CONTRI BUT I ON I S RECE I VED FROM A S T AT E P AC ( P O L I T I C A L ACT I ON C OMMI T T E E ) , L I S T T HE PA C I D EN T I F I C A T I O NNUMBER AND T HE P AC CHECK NUMBER I N THE DES I GNATED COLUMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA E T H I C S AND CAMPAI GNDI SCLOSURE BOARD .C AUT I ON : S e c t i o n 6 8 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 o p i e d f r o m r e p o r t s an d s t a t e m e 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 an y c o m m e r c i a l p u r p o s e b y a n y 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 .
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F o r I n s t r u c t i o n s , Se e Back o f Fo r mCONTRI 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 TTEENAME ( Mu s t b e s ame as o n St a t e me n t o f O r g a n i z a t i o n )
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Fo r J ~ s t r u c t i o n s , - S e e Back o f f d r mCONTRI 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 TTEE NAME ( M u s 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 d o n ). U- e z o n i , s ~'o r . _ 1 ~ c 7 c L l t x J v ~~ ' ~ ~ e , l o o L , s C . -
STATE CANDI DATES NOTE I F A C ON T A I B U T i O N I S R E CE I V E D F R OM A S T A T E P A C ( P OL 1 T I C AL A CT I O N C OMMI T T E E ) , USTTHE PAC I D E N T I F I C A m 1 0 NNUMBER AND T H E PAC CHECK NUMBER I N THE D E S I GN A T E D COL UMN A L I S T OF I D NUMBERS I S A VA I L A B L E FROMT HE I O WA E T HI C S AND C A MP A I G ND I S C L O S UR E B O A R D .CAUTI ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o w a C o 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 m e 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 t o n s o rf o r a n y c o mn i e r c i a l p u r p o s e b y a n y 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
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Fo r I n s t r u c t i o ns , - Se e Back o f Fo r mCONTRI BUTI ONS - - MONEYTAKEN I N( I n c l u d i n g c a n d i d a t e ' a p e r s o n a l f u n d s )COMMI TTEENAME ( Mu s t be s ame 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 )b e- n v l , s
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FOR I NSTRUCTI ONS, SEEBACKOFFORMEXPENDI TURES - MONEYSPENT FROMCOMMI TTEEACCOUNT
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FORI NSTRUCTI ONS, SEEBACKOF FORMEXPENDI TURES - MONEY SPENT FROMCOMMI TTEEACCOUNT
STATE PAC COMMI TTEES: NOTE: FOR CONTRI BUTI ONS MADETOSTATEWI 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 COLUMN AND THEPAC CHECK NUMBERFOREACH EXPENDI TURE. A L I ST OF I D NUMBERS I S AVAI LABLE FROMTHE I OWAETHI CS & CAMPAI GNDI SCLOSURE BOARD .
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FORI NSTRUCT I ONS, SEEBACKOF FORMCOMMI TS NAME ( Mu s 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 d o n )r . ,
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NAMEANDADDRESSOF hENDER( 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 )
; 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 mm i t t e e s t o d i s c l o $ 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 m mt t e e s . R e l a t i o n s h i p m u s t b e s h o wn 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 l n i t y ( b l o od 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 m a r r i a g e ) . ( S e e Pa ge 2 o f f o r m sp a c k e t . ) I f s u r n a me of c o n t r i b u t o r t o t h e same a s c a n d i d a t e , b u t t h e r e 1 s n o f a m l l l a 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 m n w h e n I t a p p l i e s .
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