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FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00....

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FOR INSTRUCTIONS, SEE BACK OF FORM DISCLOSURE SUMMARY PAGE COMMITTEE NAME (Must be same as on Statement of Organization) IMPORTANT: Indicate by # type -of committee you are reporting for . 0 ( 1 )Statewide/Legislafve/Judge Standing for Retention Candidate ( 2 )State PAC ( 3 )State Party { 4 )County Central Committee ( 5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Political Subdivision Candidate ( 8 )County PAC ( 9 )City PAC ( 10 )School Board or Other Political Subdivision PAC 11 ) Local Ballot Issue CANDIDATE COMMITTEES ONLY : Candidate Name Political Party (if applicable) Office Sought Late reports are subject to possible civil an U7 ATURE OF PERSON 43LING REPORT -CHECK IF AMENDMENT TO REPORT DATED istrict (if Senate or House) I AM FILING A IZ r 3 I" [) ~i REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR . (report date) Indicate by # M U Check if this is final (termination) report and attach Notice of Dissolution Fort DR-3. (You must continue to file reports until a DR-3 is filed .) ( - G -~ ) - 3Q - ZG 7Z l7 C~tr . TELEPHONE DATE SIGNED STATEMENT OF CASH ON HAND CASH ON HAND at the beginning of the reporting period . (Total of all funds held by the committee. This amount MUST be the same as the cash on hand at the end of the last reporting period or must be zero if this is first report filed .) . .. .... .. ... ... .. ... .... .. .... . ........ ... . $ 2frZ. ADD TOTAL MONEY TAKEN IN THIS PERIOD Schedule A : Cash Contributions total (Attach Schedule A) (*also see in-kind below) .. .... . .... . .... . . Schedule F : Loans Received total (Attach Schedule F) .. . .... .. .... . .. .. . .... . ..... . .......... .. .... . .. ... . .... . ...... Schedule H: Total Sates of Campaign Property (Attach Schedule H) ... . ..... . .... . .... . ..... . .. ... . .... . .... .. (Schedule H applies to Candidates' Committees_Only) SUBTRACT TOTAL MONEY SPENT THIS PERIOD Schedule B: Expenditures total (Attach Schedule B) (**also see debts and loans below) .. . ... .. ... . Schedule F: Loan Repayments total (Attach Schedule F) .. ......... .. ... . .... ... ... . .... ... ... . ..... .. ... ...... .. ... . CASH ON HAND at the end of this reporting period (if final report balance must be zero) (Attach DR-3) .. . .... . ... .. ... .. . ... .. ......... . .... ...... .. ..... . ... .. ......... .. ... . .... .. .... . ... ............. .. ..... . ... .. ... . $ FORM DR-2 I DISCLOSURE (Rev . =2004) REPORT Scanned Computer Audited Local Committees, enter Date of Election County & Local Committees, enter County In which Election is held SUB-TOTAL .. .. ... .. ... .. .. $ 3 `7 ` 7. `7 ~ 7 3 tr 1 'Z *"UNPAID BILLS (From Schedule D - Attach Schedule D) ... .. ..... . ... .. .... . .... .. ... . ..... .. ... . .. ... .. ... . ..... .. ... .. . ... .. ... . $ *IN KIND CONTRIBUTIONS (From Schedule E-Attach Schedule E) ... . ... .. . .. ... ... .. ... ... ... .. .......... . ..... . ... .. ... .$ Z. 94, *"OUTSTANDING LOANS (From Schedule F - Attach Schedule F) ....... . .... . ......... .. ...... ... .. ... . ..... ....... . ... .. ... . $ CONSULTANT BREAKDOWN (Schedule G Attached?) -YES - NO CANDIDATE COMMITTEES ONLY: VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H) $ STATE COMMITTEES : Submit a reconciled campaign account bank statement in January of each year .
Transcript
Page 1: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

FOR INSTRUCTIONS, SEEBACK OF FORMDISCLOSURE SUMMARY PAGE

COMMITTEE NAME (Must be same as on Statement of Organization)

IMPORTANT: Indicate by # type -ofcommittee you are reporting for.0( 1 )Statewide/Legislafve/Judge Standing for Retention Candidate ( 2 )State PAC ( 3 )State Party{ 4 )County Central Committee ( 5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other PoliticalSubdivision Candidate ( 8 )County PAC ( 9 )City PAC ( 10 )School Board or Other Political Subdivision PAC11 ) Local Ballot Issue

CANDIDATECOMMITTEES ONLY:Candidate Name

Political Party (if applicable)

Office Sought

Late reports are subject to possible civil an

U7ATURE OF PERSON43LING REPORT

-CHECK IF AMENDMENTTO REPORT DATED

istrict (if Senate or House)

I AM FILING A

IZ r 3 I" [) ~i

REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR .(report date)

Indicate by# M

U Check if this is final (termination) report and attach Notice of Dissolution Fort DR-3.(You must continue to file reports until a DR-3 is filed .)

( -G -~) -3Q - ZG 7Z

l7 C~tr.TELEPHONE

DATE SIGNED

STATEMENT OF CASH ON HANDCASH ON HAND at the beginning ofthe reporting period . (Total of all funds held by the

committee. This amount MUST be the same as the cash on hand at the endof the last reporting period or must be zero if this is first report filed .) . .. . . . . .. . . . ... . . ... . . . . .. . . . . . . . . . . . . . ... . $

2frZ.

ADD TOTALMONEYTAKEN IN THIS PERIODSchedule A: Cash Contributions total (Attach Schedule A) (*also see in-kind below) .. . . . . . . . . . . . . . . ..Schedule F: Loans Received total (Attach Schedule F) . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . .Schedule H: Total Sates of Campaign Property (Attach Schedule H) . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . ..

(Schedule H applies to Candidates' Committees_Only)

SUBTRACT TOTAL MONEY SPENTTHIS PERIODSchedule B: Expenditures total (Attach Schedule B) (**also see debts and loans below) . . . . . . .. . . . .Schedule F: Loan Repayments total (Attach Schedule F) .. . . . . . . . . . .. . . . . . . . . ... . . . . . . . . ... . . . . . . . . . .. . . . .. . . . . .. . . . .

CASH ON HAND at the end of this reporting period (if final report balance mustbe zero) (Attach DR-3) . . . . . . . . . . . .. . . . .. . . . . .. . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. . . . . $

FORMDR-2

I DISCLOSURE(Rev . =2004)

REPORT

ScannedComputerAudited

Local Committees, enterDate of Election

County & Local Committees, enter County Inwhich Election is held

SUB-TOTAL.. . . ... . . ... . . .. $

3`7 7̀. `7

~7 3 tr

1 'Z

*"UNPAID BILLS (From Schedule D - Attach Schedule D) . . . .. . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . . .. . . . . .. . . . .. . . . . . . . . . .. . . . .. . . . . .. . . . .$*IN KIND CONTRIBUTIONS (From Schedule E-Attach Schedule E) . . . . . . . .. . . . ... . . . .. . . . ... . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . .$

Z. 94,*"OUTSTANDING LOANS (From Schedule F - Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . .. . . . . . . . . . .. . . . . . . . . . .. . . . .$CONSULTANT BREAKDOWN (ScheduleGAttached?)

-YES -NOCANDIDATE COMMITTEES ONLY:VALUEOF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H)

$STATECOMMITTEES : Submit a reconciled campaign account bank statement in Januaryof each year .

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SUB-TOTALTOTAL(if last page of this schedule)

Page-1- of-14 -(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTSCOMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

1/17/2005 ID # Larry d'Autrmont4205 Kelling Ct

Ck # Davenport IA 52806 15 .001/17/2005 ID # Bill Gluba

2421 Gaines StCk # Davenport IA 52803 10.00

1/17/2005 ID # Frank Wood1135 W Davies St

Ck # Eldridge IA 52748 25 .001/17/2005 ID # Mark Henderson

4 Manor Dr Apt C-6Ck # Eldridge IA 52748 15 .00

1/17/2005 ID # Helen Roberson5410 Marquette

Ck # Davenport IA 52806 20.001/17/2005 ID # Joe Winckler

6 Thode CtCk # Davenport IA 52802 25.00

1/17/2005 ID # Tom Engelmann4552 Main St

Ck # Davenport IA 52806 50.001/17/2005 ID # Miscellaneous

UnitemizedCk # Cash 226.00

2/2/2005 ID # Leslie Cavendish1520 Terrace Park Dr

Ck # Bettendorf IA 52722 25.002/2/2005 ID # Mary Ann Roth

3319 MarquetteCk # Davenport IA 52806 100.00

2/2/2005 ID # Tom Engelmann4552 Main St

Ck # Davenport IA 52806 200.00

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SUB-TOTALTOTAL(if last page of this schedule)

Page

2-of- 14(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTSCOMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

2/2/2005 ID # John Cameron4510 Apple Valley Dr

Ck # Bettendorf IA 52722 100.002/9/2005 ID # 8036 Electrical Workers LU 145 PAC

1700 52nd AveCk # 2502 Moline IL 61265 250 .00

2/9/2005 ID # Mark Henderson4 Manor Dr C-6

Ck # Eldridge IA 52748 50.002/9/2005 ID # Rebecca Oliver

3609 Somerset DrCk # Bettendorf IA 52722 25 .00

2/9/2005 ID # John Bowman18 Wildwood Tr

Ck # Bettendorf la 52722 100.002/9/2005 ID # Alta Price

4888 School House RdCk # Bettendorf IA 52722 100.00

2/9/2005 ID # MiscellaneousUnitemized

Ck # Cash 14.472/9/2005 ID # Karl Rhomberg

3330 TremontCk # Davenport IA 52803 100.00

2/9/2005 ID # Elizabeth Brooke5605 wisconsin Ave

Ck # Davenport IA 52806 100.002/9/2005 ID # Winstein, Kavensky & Wallace

224 18th StreetCk # Rock Island IL 61201 200.00

2/9/2005 ID # Friends of Bill GlubaP .O. Box 2205

Ck # Davenport IA 52809 100.00

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SUB-TOTALTOTAL(if last page of this schedule)

Page

3-of- 14(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTSCOMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

2/11/2005 ID # Lou Waechter2127 Marquette

Ck # Davenport IA 52804 50.002/11/2005 ID # Ernest Klingaman

411 Holland StCk # LeClaire IA 52753 50.00

2/11/2005 ID # Caroline Vernon1704 Farnum St

Ck # Davenport IA 52803 25 .002/11/2005 ID # Tom Frizsche

2815 E Central ParkCk # Davenport IA 52803 100 .00

2/11/2005 ID # Joe Seng4804 Northwest Blvd

Ck # Davenport IA 52806 25.002/11/2005 ID # Frank Wood

1135 DaviesCk # Eldridge la 52748 100.00

2/11/2005 ID # Cathy Hermes2307 Grove St

Ck # Davenport IA 52804 50.002/11/2005 ID # 8048 Millwright LU 2148 PAC

2707 62nd Street CtCk # 1138 Bettendorf IA 52722 350.00

2/11/2005 ID # Braley for CongressP .O . Box 390

Ck # Waterloo IA 50704 200.002/14/2005 ID # Kenton Allen

6522 Thomas CtCk # Bettendorf IA 52722 100 .00

2/14/2005 ID # Betty Drumm611 Northbrook Dr

Ck # Davenport IA 52806 25.00

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SUB-TOTALTOTAL(if last page of this schedule)

Page

4-of-14(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

2/14/2005 ID # Calvin Drumm611 Norhtbrook Dr

Ck # Davenport IA 52806 25.002/14/2005 ID # Marla Lindemier

1514 PerryCk # Davenport IA 52803 50 .00

2/14/2005 ID # Friend of Jim Lykam2906 W 35th Street

Ck # Davenport IA 52806 100 .002/14/2005 ID # Daid Swim

3852 MarquetteCk # Davenport IA 52806 100.00

2/14/2005 ID # Tamara Van Hoosier3499 Fairview Dr

Ck # Bettendorf IA 52722 50 .002/14/2005 ID # Intl Assoc of Machinist LU 1191

Ck # Moline IL 61265 75 .002/16/2005 ID # Patrick Cummings

2703 Iowa StCk # Davenport IA 52803 25.00

2/16/2005 ID # Michael Shinners3602 N Linwood

Ck # Davenport la 52806 25 .002/16/2005 ID # William Chamberlin

514 W 16th StreetCk # Davenport IA 52803 50.00

2/16/2005 ID # Celia Rangel2514 McKinley

Ck # Davenport la 52804 50.002/16/2005 ID # Fitzsimmons for Auditor

3510 RockinghamCk # Davenport IA 52802 100 .00

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SUB-TOTALTOTAL(if last page ofthis schedule)

Page

5-of_14-(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTSCOMMITTE NAME

Scott County Democrats

PAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNTDATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVED

RECEIVED PAC check (if applicable)(MM/DD/YR) Number

2/16/2005 ID # MiscellaneousUnitemized

Ck # Cash 105 .002/16/2005 ID # Joe & Cindy Winckler

6 Thode StCk # Davenport IA 52802 200.00

2/16/2005 ID # Susan FF Pamperin2718 College

Ck # Davenport IA 52803 200 .002/16/2005 ID # United Autoworkers LU 1896

3102 RockinghamCk # Davenport IA 52802 250.00

2/16/2005 ID # United Steelworkers LU 105880 Deveils Glen

Ck # Bettendorf IA 52722 250.002/18/2005 ID # Cathy Berta

2831 Taylor StCk # Davenport IA 52804 25 .00

2/18/2005 ID # Donan McAuley1747 Cindy Ct

Ck # Bettendorf IA 52722 50.002/18/2005 ID # Margaret Mackin

3111 Parkwild DrCk # Bettendorf IA 52722 50.00

2/18/2005 ID # Ed Brown2615 Iowa St

Ck # Davenport IA 52803 100 .002/18/2005 ID # Martha Easter Wells

2630 Iowa StreetCk # Davenport IA 52803 200.00

2/18/2005 ID # Plumbers & Pipefitters LU25 Iowa State PAC4600 46th Avenue

Ck # Rock Island IL 61201 200.00

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SUB-TOTALTOTAL(if last page ofthis schedule)

Page

6^of_14-(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTSCOMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

2/21/2005 ID # Patricia Sheller2514 Cypress Dr

Ck # Bettendorf IA 52722 25 .002/21/2005 ID # Cliff Day

3422 Adams StCk # Davenport IA 52807 25 .00

2/21/2005 ID # Regan for Scott CountyP.O . Box 486

Ck # Priinceton IA 52768 25 .002/21/2005 ID # June Gillespie

3416 W ColumbiaCk # Davenport IA 52804 25 .00

2/21/2005 ID # Tina Clawson2230 N linwood

Ck # Davenport IA 52804 25.002/21/2005 ID # Miscellaneous

UnitemizedCk # Cash 285 .00

2/21/2005 ID # Joel Franken1610 Prospect Terrace

Ck # Davenport IA 52803 25 .002/21/2005 ID # Tom Wolfe

1905 emerald DrCk # Davenport IA 52804 25 .00

2/21/2005 ID # Greg Fitzpatrick2104 Farnam St

Ck # Davenport IA 52803 25.002/21/2005 ID # Elesha Gayman

1515 Kenosha CtCk # Davenport IA 52804 25 .00

2/21/2005 ID # CliffDay3422 Adams St

Ck # Davenport IA 52807 25.00

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SUB-TOTALTOTAL(if last page of this schedule)

Page

7-of_14-(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

2/21/2005 ID # Bev Strayhall4407 E 48th Street

Ck # Davenport IA 52807 25.002/21/2005 ID # Virginia Lazio

5600 Jersey Ridge Rd Apt 03Ck # Davenport IA 52807 25.00

2/21/2005 ID # Larry Roberson5410 N Marquette

Ck # Davenport IA 52806 50 .002/21/2005 ID # Nancy McConnell

5376 Surrey DrCk # Bettendorf IA 52722 50 .00

2/21/2005 ID # Rebekah Gayman1515 Kenosha Ct

Ck # Davenport IA 52804 50.002/21/2005 ID # Florence Whisler

517 W Prairie Vista DrCk # Eldridge IA 52748 50.00

2/21/2005 ID # Ken Krayenhagen2822 Arlington

Ck # Davenport IA 52803 50.002/21/2005 ID # Julie M Ross

2421 Iowa StCk # Davenport IA 52803 50.00

2/21/2005 ID # Janice Boyd3751 Deer Spring Dr

Ck # Bettendorf IA 52722 50.002/21/2005 ID # Maragret M Deluhery

629 Foster DrCk # Des Moines IA 50312 50.00

2/21/2005 ID # Anna Gibeault4604 Spring St

Ck # Davenport IA 52807 100.00

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SUB-TOTALTOTAL(if last page ofthis schedule)

Page _8- of_14-(for Schedule A)

CONTRIBUTIONS - MONEYTAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

2/21/2005 ID # Thomas K Anderson2202 E 48th Street

Ck # Davenport IA 52807 100.002/21/2005 ID # AFSCME Council 61 People

4320 NW 2ndCk # 3056 Des Moines IA 50313 200.00

2/28/2005 ID # 8178 Local 150 - Intl Union Oper Engineer - LAPAC6200 Joliet Rd

Ck # 2761 Countryside IL 60525 200.003/8/2005 ID # Miscellaneous

UnitemizedCk # Cash 97.00

3/11/2005 ID # MiscellaneousUnitemized

Ck # Cash 28.003/21/2005 ID # Larry d'Autrmont

4205 Kelling CtCk # Davenport IA 52806 20.00

3/21/2005 ID # Monica Kurth415 E 14th Street

Ck # Davenport IA 52803 20.003/21/2005 ID # Cliff Day

3422 Adams StCk # Davenport IA 52807 10.00

3/21/2005 ID # Elesah Gayman1515 Kenosha Ct

Ck # Davenport IA 52804 20.003/21/2005 ID # Ken Krayenhagen

2822 ArlingtonCk # Davenport IA 52803 10.00

3/21/2005 ID # Bill Gluba2421 Gaines

Ck # Davenport IA 52804 10 .00

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SUB-TOTALTOTAL(if last page of this schedule)

Page

9-of-14-(for Schedule A)

CONTRIBUTIONS - MONEYTAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DDNR) Number

3/21/2005 ID # Anna Gibeault4604 Spring St

Ck # Davenport IA 52807 80.003/21/2005 ID # Miscellaneous

UnitemizedCk # Cash 608 .20

4/18/2005 ID # MiscellaneousUnitemized

Ck # Cash 10.004/19/2005 ID # Ken Krayenhagen

2822 ArlingtonCk # Davenport IA 52803 20.00

4/19/2005 ID # Alison Hart335 W 29th Street

Ck # Davenport IA 52803 10 .004/19/2005 ID # Miscellaneous

UnitemizedCk # Cash 200 .00

5/23/2005 ID # Susan FF Pamperin1011 1/2 E Central Park

Ck # Davenport IA 52803 10.005/23/2005 ID # Miscellaneous

UnitemizedCk # Cash 189.20

6/10/2005 ID # Audrey Linville1127 W 15th Street

Ck # Davenport IA 52804 10.006/10/2005 ID # Miscellaneous

UnitemizedCk # Cash 93.28

7/12/2005 ID # MiscellaneousUnitemized

Ck # Cash 11 .00

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SUB-TOTALTOTAL(if last page of this schedule)

Page

10-of-14-(for Schedule A)

CONTRIBUTIONS - MONEYTAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DDNR) Number

7/12/2005 ID # Tom Engelmann4552 Main Street

Ck # Davenport IA 52806 200.007/15/2005 ID # Miscellaneous

UnitemizedCk # Cash 88.00

8/1/2005 ID # Ken Krayenhagen2822 Arlington

Ck # Davenport IA 52803 10.008/1/2005 ID # Miscellaneous

UnitemizedCk # Cash 53.72

8/12/2005 ID # Rita Vargas2724 LeClaire

Ck # Davenport IA 52803 45 .008/12/2005 ID # Tom Engelmann

4552 Main StreetCk # Davenport IA 52806 500.00

8/12/2005 ID # MiscellaneousUnitemized

Ck # Cash 90.008/24/2005 ID # Shawver & Shawver

2805 EasternCk # Davenport IA 52803 100.00

8/24/2005 ID # Dennis DeDecker3400 Central Ave

Ck # Bettendorf IA 52722 250.008/24/2005 ID # Paul Elgatian

4315 Jersey RidgeCk # Davenport IA 52807 50.00

8/24/2005 ID # Marlin H Volz2304 Wynnewood Ct

Ck # Davenport IA 52807 100.00

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SUB-TOTALTOTAL(if last page of this schedule)

Page111- of,14`(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

8/24/2005 ID # Lou Waechter2127 Marquette

Ck # Davenport IA 52804 100.009/8/2005 ID # Chris Gallin

2217 E 45th StreetCk # Davenport IA 52807 25 .00

9/8/2005 ID # Achim Kukarans6012 116th Street

Ck # Blue Grass IA 52726 20 .009/8/2005 ID #8036 Electrical Worlers LU 145 PAC

1700 52nd AveCk # 2539 Moline IL 61265 500.00

9/12/2005 ID # Tom Engelmann4522 Main Street

Ck # Davenport IA 52806 25 .009/12/2005 ID # Friends of Bill Gluba

P.O . Box 2205Ck # Davenport IA 52809 25 .00

9/12/2005 ID # Cathy Hermes2307 Grove Street

Ck # Davenport IA 52804 25 .009/12/2005 ID # Audrey Linville

1127 W 15th StreetCk # Davenport IA 52804 25 .00

9/12/2005 ID # Dennis DeDecker3400 Central Ave

Ck # Bettendorf IA 52722 25.009/12/2005 ID # Cynthia Campbell

Ck # Davenport IA 52803 25.009/12/2005 ID # Marty O'Boyle

516 N 6th StreetCk # Eldridge IA 52748 25.00

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(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

9/12/2005 ID # MiscellaneousUnitemized

Ck # Cash 63 .209/21/2005 ID # 8177 Laborer's Local 309 PAC

2835 7th AveCk # 3268 Rock Island IL 61201 500.00

9/21/2005 ID # MiscellaneousUnitemized

Ck # Cash 116.009/29/2005 ID # Dennis DeDecker

3400 Central AveCk # Bettendorf IA 52722 250.00

9/29/2005 ID # Bill Gluba2421 Gaines

Ck # Davenport IA 52804 25 .0010/17/2005 ID # Miscellaneous

UnitemizedCk # Cash 86.90

10/25/2005 ID # Rita Vargas2724 LeClaire

Ck # Davenport IA 52803 45.0010/25/2005 ID # Miscellaneous

UnitemizedCk # Cash 35.00

I1/l/2005 ID # Ken Krayenhagen2822 Arlington

Ck # Davenport IA 52803 20.00l1/l/2005 ID # Peter De Kock

3759 West 9th Apt 11Ck # Waterloo IA 50702 35.00

11/1/2005 ID # Braley for CongressP.O . Box 390

Ck # Waterloo IA 50704 20.00

SUB-TOTAL 1,196 .10TOTAL(if last page of this schedule)

Page _12 of-14-

Page 14: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

SUB-TOTALTOTAL(if last page of this schedule)

Page -13

of_14-(for Schedule A)

CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTS

COMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

11/1/2005 ID # Henry Vargas517 E Central Park

Ck # Davenport IA 52803 31 .0011/1/2005 ID # Tom Engelmann

4552 Main StreetCk # Davenport IA 52806 36.00

1l/l/2005 ID # Margo Marin5600 Jersey Ridge E-1

Ck # Davenport IA 52807 10.001l/l/2005 ID # Ruth Quick

5723 Gaines StCk # Davenport IA 52806 10.00

l 1/1/2005 ID # Lou Waechter2127 Marquette

Ck # Davenport IA 52804 20.0011/1/2005 ID # Rick Dickinson for Congress

P.O. Box 566Ck # Dubuque IA 52004 20.00

11/1/2005 ID # Ken Krayenhagen2822 Arlington

Ck # Davenport IA 52803 40.0011/1/2005 ID # Molly Regan

P .O . Box 486Ck # Princeton IA 52768 10.00

11/1/2005 ID # Joe & Cindy Winckler6 Thode Ct

Ck # Davenport IA 52802 50.0011/1/2005 ID # James Hood

220 Emerson PICk # Davenport IA 52801 100.00

l1/l/2005 ID # Tom Engelmann4552 Main Street

Ck # Davenport IA 52806 50 .00

Page 15: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

SUB-TOTALTOTAL(if last page of this schedule)

5,966.458,093 .42

Page _14

of-14(for Schedule A)

I CONTRIBUTIONS - MONEY TAKEN IN SCHEDULE A MONETARY

RECEIPTSCOMMITTE NAME

Scott County DemocratsPAC ID # NAME AND ADDRESS RELATIONSHIP AMOUNT

DATE (if applicable) OF CONTRIBUTOR TO CANDIDATE* RECEIVEDRECEIVED PAC check (if applicable)(MM/DD/YR) Number

11/1/2005 ID # MiscellaneousUnitemized

Ck # Cash 287.0011/15/2005 ID # Davenport Democratic Party

4552 Main StreetCk # 944 Daveport IA 52806 60.12

11/15/2005 ID # MiscellaneousUnitemized

Ck # Cash 18 .0011/21/2005 ID # Citizens for Henderson

4 Manor Dr C-6Ck # Eldridge IA 52748 5,000.00

11/21/2005 ID # Martha Easter Wells2630 Iowa St

Ck # Davenport IA 52803 250.0011/21/2005 ID # Cathy Hermes

2307 Grove StreetCk # Davenport IA 52804 10.00

11/21/2005 ID # MiscellaneousUnitemized

Ck # Cash 64.0012/15/2005 ID # A Guard for State Representative

Attn H Volz 203 W 3rd StCk # Davenport IA 52803 17 .64

12/15/2005 ID # Davenport Democratic Party4552 Main Street

Ck # 945 Davenport IA 52806 201 .6912/22/2005 ID # Miscellaneous

UnitemizedCk # Cash 58.00ID #

Ck #

Page 16: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

. EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT SCHEDULE B

SUB-TOTALTOTAL(if last page of this schedule)

MONETARY

EXPENDITURES

Page-1- of

8(for Schedule B)

COMMITTE NAME

Scott County DemocratsCandidate NAME AND ADDRESS TO PURPOSE AMOUNT

DATE ID # and WHOM EXPENDITURE (DESCRIBE EXPENDEDEXPENDED PAC check (Disbursement) WAS MADE TRANSACTION)(MM/DD/YR) Number

1/3/2005 Postmaster933 W 2nd Street

1535 Davenport IA 52802 Postage 161 .001/7/2005 The Plaza

1416 W 16th Street1536 Davenport IA 52804 Rent 550.00

1/11/2005 Lisa Froelich3804 Chisolm Tr

1537 Davenport IA 52804 Election Day Work 99.001/11/2005 Shirley Jones

1538 Election Day Work 99.001/11/2005 Auto Owners Insurance

P .O . Box 303151539 Lansing MI 48909 Liability Ins 413 .00

1/11/2005 Postmaster933 W 2nd Street

1540 Davenport IA 52802 Permit 150 .001/11/2005 Review Printing Co

311 21st St1541 Rock Island IL 61201 Postcard printing 48.00

1/12/2005 Audrey Linville Ink 58.841127 W 15th Street Paper 25.67

1542 Davenport IA 52804 Postage 69 .00 153 .511/12/2005 Cathy Hermes

2307 Grove Street1543 Davenport IA 52804 Postage 23 .00

1/25/2005 Audrey Linville Postage 60.001127 W 15th Street Envelopes 26 .72

1544 Davenport IA 52804 86 .722/2/2005 Review Printing Co

311 21st St1545 Rock Island IL 61201 Tickets Printing 320.00

Page 17: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT SCHEDULE B

SUB-TOTALTOTAL(if last page of this schedule)

MONETARY

EXPENDITURES

Page 2- of-8(for Schedule B)

COMMITTE NAME

Scott County DemocratsCandidate NAME AND ADDRESS TO PURPOSE AMOUNT

DATE ID # and WHOM EXPENDITURE (DESCRIBE EXPENDEDEXPENDED PAC check (Disbursement) WAS MADE TRANSACTION)(MM/DD/YR) Number

2/2/2005 Kevin Pamperin2718 College Stage Building Mtls

1546 Davenport IA 52803 103.022/2/2005 Susan FF Pamperin

2718 College1547 Davenport IA 52803 Office supplies 351 .69

2/2/2005 The Plaza1416 W 16th Street

1548 Davenport IA 52804 Rent 550 .002/2/2005 Audrey Linville Awards Plaques

1127 W 15th Street 132.251549 Davenport IA 52804 Postage 162.00 294.25

2/10/2005 Audrey Linville Postage 672.641127 W 15th Street Labels 27 .68

1550 Davenport IA 52804 700.322/11/2005 Postmaster

933 W 2nd Street1551 Davenport IA 52802 Postage 315 .70

2/14/2005 LULAC Club4800 Ricker Hill Rd

1552 Davenport IA 52802 Hall Rent 100.002/18/2005 Cash -

Counter Change Fund RWBCheck Change Fund 300.00

2/21/2005 Deposit Change Fund

(300.00)3/8/2005 The Plaza

1416 W 16th Street1553 Davenport IA 52804 Rent 550.00

3/8/2005 The Leader Newspaper1600 5th Avenue

1554 Moline IL 61265 Advertising 88 .20

Page 18: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

I EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT SCHEDULE B

SUB-TOTALTOTAL(if last page of this schedule)

MONETARY

EXPENDITURES

Page

3-of-8-(for Schedule B)

COMMITTE NAME

Scott County DemocratsCandidate NAME AND ADDRESS TO PURPOSE AMOUNT

DATE ID # and WHOM EXPENDITURE (DESCRIBE EXPENDEDEXPENDED PAC check (Disbursement) WAS MADE TRANSACTION)(MM/DD/YR) Number

3/10/2005 Cathy Hermes Ads 132.202307 Grove Street Office Supp 30.22

1555 Davenport IA 52804 Postage 43 .56 205 .983/19/2005 Cash -

Change Fund Trivia1556 Change Fund 100.00

3/21/2005 Deposit Change Fund

(100.00)3/19/2005 Thoma Enterprises/ Jeffs Market

408 6th Ave Red White Blue1557 Durant IA 52747 Caterer 1,295 .77

3/19/2005 QwestP.O . Box 91104

1558 Seatlle WA 98111 Phone Service 70.513/19/2005 Mitch Tollerud

1626 W Geo Wash Blvd 5 years1559 Davenport IA 52804 Domain Registry 99 .95

3/21/2005 Sherry's Rainbow Florist Funeral3030 Rockingham Rd Darlene Hill

1560 Davenport IA 52802 Flowers 47 .803/21/2005 Missippi Vally Fair Red White Blue

2815 W Locust Tablecloths 82 .001561 Davenport IA 52804 Security 90.00 172 .00

3/19/2005 Friendly House1221 Myrtle

1562 Davenport IA 52804 Hall Rent 40 .003/29/2005 Dennis DeDecker

3400 Central Ave Trivia Questions1563 Bettendorf IA 52722 62 .50

4/4/2005 The Plaza1416 W 16th Street

1564 Davenport IA 52804 Rent 550.00

Page 19: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

I EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT SCHEDULE B MONETARY

SUB-TOTALTOTAL(if last page of this schedule)

EXPENDITURES

Page 4- of-8-(for Schedule B)

COMMITTE NAME

Scott County DemocratsCandidate NAME AND ADDRESS TO PURPOSE AMOUNT

DATE ID # and WHOM EXPENDITURE (DESCRIBE EXPENDEDEXPENDED PAC check (Disbursement) WAS MADE TRANSACTION)(MM/DD/YR) Number

4/4/2005 Review Printing Co311 21st St

1565 Rock Island IL 61201 Newsletter printing 438 .154/15/2005 Cash -

Change Fund Trivia1566 Change Fund 100.00

4/19/2005 Deposit Change Fund

(100.00)4/19/2005 North Scott Press

214 N 2nd Street Trivia1567 Eldridge IA 52748 Ads 88 .00

4/19/2005 Cathy Hermes2307 Grove Street Trivia

1568 Davenport IA 52804 Ads 88 .204/19/2005 Qwest

P.O . Box 911041569 Seadle WA 98111 Phone Service 83 .75

4/19/2005 Postmaster1570 933 W 2nd Street1571 Davenport IA 52802 Box Rental 68 .00

4/25/2005 Missippi Vally Fair2815 W Locust Fair Booth Rent

1572 Davenport IA 52804 450.005/2/2005 North Scott Press

214 N 2nd Street Trivia1573 Eldridge IA 52748 Ads 39 .60

5/2/2005 Sherry's Rainbow Florist Funeral3030 Rockingham Rd Kathy Kirshbaum

1574 Davenport IA 52802 Flowers 52 .155/2/2005 The Plaza

1416 W 16th Street1575 Davenport IA 52804 Rent 550.00

Page 20: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT

SCHEDULE B MONETARY

EXPENDITURES

(for Schedule B)

COMMITTE NAME

Scott County DemocratsCandidate NAME AND ADDRESS TO PURPOSE AMOUNT

DATE ID # and WHOM EXPENDITURE (DESCRIBE EXPENDEDEXPENDED PAC check (Disbursement) WAS MADE TRANSACTION)(MM/DD/YR) Number

5/12/2005 First Distrrict Democratic Central Committee801 Sheridan Rd Dues 65 .00

1576 Waterloo IA 50701 Ad 100.00 165 .005/12/2005 Tom Engelmann

4552 Main Street Trivia1577 Davenport IA 52806 Ad 88.20

5/12/2005 PC Paramedics145 W 4th Street Repairs on

1578 Coal Valley IL 61240 Computer 70.005/21/2005 Cash -

Change Fund Trivia1579 Change Fund 100.00

5/21/2005 LULAC Club4800 Ricker Hill Rd

1580 Davenport IA 52804 Hall Rent 100.005/23/2005 Deposit Change Fund

(100.00)6/3/2005 The Plaza

1416 W 16th Street1581 Davenport IA 52804 Rent 550.00

6/9/2005 QwestP.O . Box 91104

1582 Seatlle WA 98111 Phone Service 83 .756/9/2005 Audrey Linville

1127 W 15th Street1583 Davenport IA 52804 Postage 46.00

6/28/2005 Internet RevealedP.O . Box 1023 E Mail List server

1584 Moline IL 61265 web Hosting 1 year 164.006/28/2005 The Plaza

1416 W 16th Street1585 Davenport IA 52804 Rent 550.00

SUB-TOTAL 1,816.95TOTAL(if last page of this schedule)

Page 5 of-8-

Page 21: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT

SCHEDULE B MONETARY

SUB-TOTALTOTAL(if last page of this schedule)

EXPENDITURES

Page

6

of-8-(for Schedule B)

COMMITTE NAME

Scott County DemocratsCandidate NAME AND ADDRESS TO PURPOSE AMOUNT

DATE ID # and WHOM EXPENDITURE (DESCRIBE EXPENDEDEXPENDED PAC check (Disbursement) WAS MADE TRANSACTION)(MM/DDIYR) Number

7/19/2005 Cathy Hermes Candy Parade 31 .432307 Grove Street Ad Trivia 44.00

1586 Davenport IA 52804 Shelter Rent 30.00 105.437/19/2005 Dennis DeDecker

3400 Central Ave Shelter Rent 30.001587 Bettendorf IA 52722 30 .00

7/26/2005 Postmaster933 W 2nd Street

1589 Davenport IA 52802 Postage 23 .008/1/2005 The Plaza

1416 W 16th Street1590 Davenport IA 52804 Rent 550.00

8/8/2005 Quad City Labor Day Parade Alliance

1591 Davenport IA 52807 Ad & Entry Fee 110.008/15/2005 Qwest

P.O . Box 911041592 Seatlle WA 98111 Phone Service 465 .07

8/15/2005 Davenport NAACP Branch 4019P.O . Box 3661 Ad & Table at event

1593 Davenport IA 52808 400.009/1/2005 The Plaza

1416 W 16th Street1594 Davenport IA 52804 Rent 550.00

9/19/2005 Office Max320 w Kimberly Toner Cartridge

1595 Davenport IA 52806 78 .009/22/2005 Review Printing Co

311 21st St1596 Rock Island IL 61201 Printing letters 409.50

10/5/2005 The Plaza1416 W 16th Street

1597 Davenport IA 52804 Rent 550.00

Page 22: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

EXPENDITURES - MONEY SPENT FROM COMMITTEEACCOUNT SCHEDULE B

SUB-TOTALTOTAL(if last page of this schedule)

MONETARY

EXPENDITURES

Page

7-of- 8-(for Schedule B)

COMMITTE NAME

Scott County DemocratsCandidate NAME AND ADDRESS TO PURPOSE AMOUNT

DATE ID # and WHOM EXPENDITURE (DESCRIBE EXPENDEDEXPENDED PAC check (Disbursement) WAS MADE TRANSACTION)(MM/DD/YR) Number

10/20/2005 Audrey Linville1127 W 15th Street

1598 Davenport IA 52804 Fair passes 88 .0010/25/2005 Qwest

P .O. Box 911041599 Seatlle WA 98111 Phone Service 266.66

11/4/2005 The Plaza1416 W 16th Street

1600 Davenport IA 52804 Rent 550.0011/8/2005 The Rusty Nail

2800 W Locust1602 Davenport IA 52804 Party 60.12

11/19/2005 Auto Owners InsuranceP .O. Box 30315

1603 Lansing MI 48909 Liability Ins 438.0011/29/2005 Missippi Vally Fair

2815 W Locust RWB Hall Rent1604 Davenport IA 52804 750.00

11/30/2005 The Plaza1416 W 16th Street

1605 Davenport IA 52804 Rent 550.0012/1/2005 Cathy Hermes

2307 Grove Street Postage1606 Davenport IA 52804 48.99

12/1/2005 First Distrrict Democratic Central Committee801 Sheridan Rd

1608 Waterloo IA 50701 Donation 350.0012/15/2005 Qwest

P.O. Box 911041609 Seatlle WA 98111 Phone Service 535 .25

12/15/2005 Susan FF Pamperin1011 1/2 E Central Park Postage

1610 Davenport IA 52803 181 .18

Page 23: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT

SCHEDULE B MONETARY

SUB-TOTALTOTAL(if last page of this schedule)

EXPENDITURES

(99.00)365 .92

Page

8

of-8-(for Schedule B)

COMMITTE NAME

Scott County Democrats

DATE

EXPENDED

(MM/DD/YR)

Candidate

ID # and

PAC check

Number

NAME AND ADDRESS TOWHOM EXPENDITURE

(Disbursement) WAS MADE

PURPOSE(DESCRIBE

TRANSACTION)

AMOUNTEXPENDED

12/31/2005

1538

Shirley Jones

Davenport IA 52802

VOID CHECK

Election Day Work (99 .00)

Page 24: FORINSTRUCTIONS, OFFORM DISCLOSURESUMMARYPAGE …...611 Northbrook Dr Ck# Davenport IA 52806 25.00. SUB-TOTAL TOTAL(iflast pageofthis schedule) Page 4-of-14 (forScheduleA) CONTRIBUTIONS-

FOR INSTRUCTIONS, SEEBACK OF FORM

COMMITTEENAME (Must be same as on Statement of Organization)

5 17 6

, -SCHEDULE

E IN-KIND(Rev . 06/97)1 CONTRIBUTIONS

rl CHECK THIS BOX IFAMENDING FORM

TOTAL (if last

page of this

schedule)

'Disclosure law requires candidates to disclose the relationship of any relative making an in kind contribution to the

Paget ofcommittee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives

(for Schedule E)by marriage).

(See Page 2 of forms packet.) If sumame of contributor is the same as candidate, but there is nofamilial relationship, enter "not applicable" in the relationship column .

DATERECEIVED(MM/DD/YR)

NAME ANDADDRESSOF CONTRIBUTOR

RELATIONSHIPTO CANDIDATE' (if applicable)

DESCRIPTIONOF IN KIND

CONTRIBUTION

ESTIMATEDFAIR MARKET

VALUE

~ IF FORFUND-RAISERCONTRIBUTION

y~yz /14 Nlw _a~ Z,~

r/~~1G~ l7 El

f7 7'L~'wj kev/?5 5. ~rY

`~

/~ /off a~: A)C~eL_errG-

qcr.~

l lJDY/E <`P/J-v J'4

t!

56,91

illlo 'I Lfc/~~,

F-1

71

71


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