+ All Categories
Home > Documents > Hanson Dell__1390__scanned

Hanson Dell__1390__scanned

Date post: 08-Apr-2018
Category:
Upload: zach-edwards
View: 225 times
Download: 0 times
Share this document with a friend

of 6

Transcript
  • 8/7/2019 Hanson Dell__1390__scanned

    1/6

    1 0 / 2 B/ 2 0 04 1 5 : 0 3 1 3 1 9 4 7 2 2 3 0 9, f -; l i I STRUCT I ONS , SEEBACKOF FORM

    DI SCLOSURESUMMARYPAGECOM

    I TTEENAME ( , We s t e e e as

    o f o f Cr g n i r a l i o

    I MPORTANT : I n d i c s t e t y p e o f c o mmi t t e e y o u a r e r e p or t i n g f o r :( 1 ) S t a t e w i a e / L e g i a l e t r v e Ca 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 ) Co u nt y t L o ca l Ca n d i d a t e( 5 ) Co u nt y PAC ( n ) B a l l o t l s s u wF r a n ch i s e Co mmi t t e e ( 7 ) C o u n t y y / C i t y C e n t r a l Co mmi t t e e( S ) Su p p or t S l a n g o f Ca n d i d a t e sCANDI DATECOMMI TTEES ONLY :Ca nd i d at e Na me

    a . 1 1

    1 4

    S d - . r .

    O f f i c e So u g h t

    a

    5

    Ro u t i n e Pe na l t i e s Due F o r L a t e F i l e d Repo r t s Ran ge f r o m $ 20 t o $ 8 0 0SEE I NSTRUCT I ONS ON BACK ANQCOMPLYTHE FOLLOWI NG SENTENCE :I AM F I L I NG A

    l 0 - - o Z . - L - - 0 4

    REPORT FOR AN/ A ( 1 ) ELECT I ON / ( 2 ) NON- EL ECT I ON YEAR,

    ( r e p o r t d a t e )

    I n d i c a t e o n e

    C] CHECK I F AMENDMENT TO REPORT DATED

    L o c a l Co mmi t t e e s , e n t e r Da t e o f E l e c t i o n

    0C h e c 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 a n 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 or m DR- 3 .( Y o u mus 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 . )

    STATEMENTOF CASH ON HAND

    PA ( ; E 0 1

    Fo r Of J I c s Use On i y1CComm. uI n d e xe dAu d i t e dC o m p u t e r ,

    / O- ;$ - 0DATE SI GNED

    Co ur t l y 3 L o c a l Co mmi t t e e s , e n t e r Co u n t y I nwh i c h E l e c t i o n I s h e l d

    CASH ONHAND a t t h e b eg 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 mo n l e s h e l db y t h e c o mmi t t e e . T h i s amou n t MUST b e t h e s ame a s t h e c a s h o n h a n d a t t h e e n d

  • 8/7/2019 Hanson Dell__1390__scanned

    2/6

    1 0 / 2 8 1 2 00 4 1 5 : 0 3 1 3 1 9 4 7 2 2 3 0 9

    Fc r : n s t r u c t l e r l s , Se e Back o f Fo r mCCNTRI BUTI CNS - MCNEYTAKEN 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 na l f u n d s )CCMMI TTEENAME ( Mu s t b e s ame as o n S t a t eme n t o f O r g a n i z a t i o n )

    5

    SCHEDULE( R e v . 0 6 ! 9 7 )

    PAGE 0 2

    MCNE- Ap yRE%c : P , r SCHECKT HI S eC: C ! FAMENDI NG FORM

    STATE CANDI DATES NOTc I F A C ON T RI B UT I ON I S RECEI V E D FROM A S TA TE PAC ( P o u l l c A L AC" 1ONCOMWTTE7, L I S T TME PAC I D E N T I F I C AT I O N, y U M BE 9 AND THE PACCHECK NUMBER I N THE DESI GNATED COL UMN . A UST OF I D NUMBERS 1 6 A V A I L A B L E F - - R O M TWE I OWA E T H I C S AND CAMPAI GNDI SCLOSURE BOARD .CAUT I ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o w a Code , p r o h i b d s z t 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 i i c i t i n g c o n t t i b u b o m o rf o r a n y c o mme 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 r t h a n s t a t u t o r y p o l Mc a l c o mmi t t e e s.

    DATE PAC I D NUMBER NAMEANDADDRESS OF CONTRI BUTOR RELAT I ONS H I P AMOUNT - 1 I F FARRECEIVED ( i f appl i cabl e) TO CANDI DATE" RECEI VED FUND-( MMI OOI YR) ANDPAC CHECK ( I t a p p l i c a b l e ) RAI SERNUMBER I P l C OM E

    t o - 1 9 - a q I 0 # ! o f ; . a ' T JaC" ~3. 9 3 P- 0 . ( 3 . . ~. n o t i . A / a , o 0o r ~I D# g 33g FA S - PAL F " . , . , - ,

    I O- l 9 - 0 CK# Z 4, o o E- $44 , ~ - { - / OO. o o~ r ' 1 3 4 3 ~ ~ . . a_ . ~a0 3I D f 1 ( v o . . s ( o Qw. . I ~ - + . - . c L c . . . : l . a _

    1 0 - 1 5 - 0 CK# 3 ( oXt - r f A SSa_1 a . J - . w - Ie 8 a c . uw 4 A t i d A ~ . . . , . . _ ~ , . ~ OO " C , C ,

    / o - f 9 - d CK# 9 c w~R . ~ . - , - ~ S - . , = 1 v l o o aSo , c , haac 4CK# ~a 0 7 o 1 - 4 -3 L + a . . , : . r 1 ' W . ~ . n . ~ . I an- So 3 o q - A490 L - 0 , o a II~(0 0i o - z o ' o CK# o c o 0a . a o

  • 8/7/2019 Hanson Dell__1390__scanned

    3/6

    1 0 f 2 e / 2 00 4 1 5 : 0 3 1 3 1 9 4 7 2 2 3 0 9Fo r ; n s ' r u c t l o n s , See B a c k o f F o r mCc NTRI SUr 1CNS - MONEY TAKEN I N

    ( I n c t u d 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 )

    r

    5

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

    PAGE 0 3

    SCHEDULE( Re v . 0 6 ! 9 7 ) MCNE- ARYRECS t FTS

    C3 CHECK T HI S B O) C I FAMENCI NC FORM I

    STATE CANDI DATES NOTE : I F A CONTRI B ( I n ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMI XTTEY) , L I S T THE PAC I DENT I F I CAT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATEDCOLUMN . A L I S T OF I D NUMBERS I S AVAI LaBL= r - R C M THE I OWA Er HI CS AND CAMPAI GNDI SCLOSURE BOARD.CAUTI ON : Se c t i o n 8 8 8 . 3 2 4 ( 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 ma 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 n i b u t i o r w o rf o r a n y c o mme r d a 1 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 B t i c a l c o mm i t t e e s .

    DATE PAC I D NUMBER rNAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT i 1 F FCFRECEI VED ( i f a p p t i c a b l e ) TO CANDI DATE' RECEI VED FUNQ-( MNWO/ YR) AND PAC CHECK ( I f a p p l i c a b l e ) RAI SERNUMBER MCCME

    ) o - a ( . - o y CK# o 2 ~ 3 g 1 1 4 y 3ou. Z -A o ~ . o o . oaI D#CK#I D I lCK#I DS

    _ . C ' 1 K 9I D#CKAI D#CK#

  • 8/7/2019 Hanson Dell__1390__scanned

    4/6

    10f 28120e4 15 : 0 3 13194722309 5 PAGE 04

    FOR I NSTRUCTI ONS . SEE BACKOF FORM SCHEDULEEXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT ( Re v O" 7) EXPENDI TURES

    STATE PACCOMMI TTEES : NOTE : FORCONTRf BUT10NS MADE TO STATEWI DE OR L EGI S LAT I VE ~CHECKTHI S BOXI FCANDI DATES . L I ST THE CANDI DATE I DENT I F I CAT70N NUMBER I N THE DESI GNATED COLUMNAND THEPAC CHECKNUMBER FOREACH EXPENDI TURE . A L I ST OF 1 0 NUMBERS I S AVAI LABLE FROMTHE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD.COMMI TTEENAME ( A d u s t b e same a s o n St a t e me n t o f Or p an i z a t l o r t )

    CANDI DATO NAME ANDADDRESS TOWHOM PURPOSE AMOUNTDATE 1 0 NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f spokabl e) ( O f s b u m e r n e r a f ) WASMADE( MMADO/ YR) ANDPACCHECKNUMBER

    ) o - l g - C . 7a oo 30 o . c ~ . . , Ad sCK# . 5 3 c ) a - C ' oI D# U

    10 l 9 - a ` ~ CK# - o 510 o r r u 1 ~ s ' 1 3 o L . o . 3 G,_I D # MPC . "l v - l 9 - v ' / CK# 0 0 0 0Po ~X oF ~D

    I D#~ / ~aa o 3, s , / - / 0 0 4 , 9 7cK# 7 0 ~ ,

    I D#CKSI D#

  • 8/7/2019 Hanson Dell__1390__scanned

    5/6

    10/ 28f 2004 15 : 03 13194722309

    FOR I I 4 S TRUCT j ONS , SE= BACKOF FORMCOwf TTEE DAMS ; Mu s t b e s e a r & a s o n St a t e me n t o f Or g an i mf i o n )

    5 P4GE 0 5

    SCHEDULEI N K I ND( Re v . CONTRI BU T I ONS

    C l CHECKTHI S BOXI FAMENDI NGFORM

    DATE

    RECEI VED( MWDDf YR)

    NAME AND ADDRESSOF CONTRI BUTORRELAT I ONSHI PTO CANDI DATE

    ' ( I f ap p l i c ab l e )DESCRI PTI ON

    OF I N KI NDDON TRI BUT I C NESTI MATED

    F AI R MARKETVALUE" 1 I F FORFUND - RAI SERCONTRI BUT I ON

    ) b - , 2 J _ Ot

    l o x , o o

    S

    l d - a . a - o ` f G 3. . 1 E~s o f 1A. "q~ _S Yl ' \ O i c . " - . q - So 30 s ` ~' 3, 0 0 0 " o - t s

  • 8/7/2019 Hanson Dell__1390__scanned

    6/6

    COMMI TTEE NAME( Mus l b a s a r r w o s o n S l a t e r n e n t o f 0 r g a n a a f i o n )1- J ~ A _ , o

    NOTE : T h u s s c h e d u l e r e p s

    money l o a n e d t o t h e c o m r n i l t e s % f i l c h I s d e p o s i t e d I n t h e c o mm i t t a e a c c o u n L

    TOTAL UNPAI D L OANS FROM 1 , 6 2 1 REPORTI NG PERI OD I SO- ) e eo . e nPART - MONET ARY LOANS RECEI VEDI=REPORTI NG PERI OD

    ( O i l g i n & 1 s o u r c e o f f a w n , s u c h a s a b a n k , must d e s h ow n d a Wr d p a r t y i sI n v o l v e d f n c f u d e l o a n s f r o m c a n d i d a t e 3 p a n o n a l f u n d s . )

    TOTAL ( PART 1 ) $

    ) Ooo . t r c

    ` D i s c l o s u r e l a w n s q u l r a s c a n d i d a t e w r r a r d t t . a e s t o d l s c l o e a t he r a I AUo r Mb I p o f a n y r e l a t i v ema k i n g a c a n t r i b u t i o n t o t h e o o mm ' I f e e R e l a d o n s h l p axm f b e s h own t o t h e t h i r d d e g r e e o fc on s&Wu : n t t y ( b l o o d r a l a d v e s ) a n d a f f i n i t y ( r e l a l t v e s b y m a r c t a ( 1 a ) _ ( S e e P a g e 2 o f f o r msp a c k e t . ) I t s u r n a r n e o f c o n t r i b u t o r i s t h e s ame 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 A l a lr e l a l i a u h i p , e n t e r " n o t a p p i l c a N a I n t h e r e l a t ! o mNp c o l umn when i t a p p l i e s

    PART I I - MONET ARY LOAN REPAYMENTS MADE g i l l REPORTI NO PERI OD( L o a n s f b r g k o n r n u s t b s r s p a r t a d o n S c h e d t t f e E - I n - k i n d t ; o r t f r f 6 a f i o 1 l S . )

    TOTAL CASK REPAYMENTS ( PART l l )F r o m S ched u l e E -TOTAL LOANS FORGI VEN

    $

    TOTAL OUTSTANDI NG LOANS END OF REPORT PERI OD

    ( f o r S c h a d u l a F )

    rW_ ,r . ,WW

    SC14EDUL E - jF L OANS

    ( R e v , O d l 8 8 ) RECEI VEDi REPAI DE ] CHECK THI S BOX ( F

    AMENDI NG3 FORM

    DATEREGENEDMMI DDI YR

    NAME ANDADDRESS OF LE NDER( I n c l u d e E n d o r s e r ' s Name, I f A p p U e x b i e ) REL ATI ONSHI PT O C ANDI I A Mf V c a b f e '

    AMOUNTOF LOAN

    coo .

    DATE PAI D( 1 . KWDt YR) NAME AND ADDRESS OF LENDER( i n c l u d e E n d o r s e r s Name, I t A p p l i c a b l e ) RELATI ONSHI PTO CANDI DATE`I l l i a b l e )

    AMOUNTREPAI DS


Recommended