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    FORI NSTRUCTI ONS, SEE BACK OF FORM

    DI SCLOSURE SUMMARY PACOMMTEE NAME ( Mu s tobt same aeon S ( a ( e s n e ~ t f o ' &I MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y o u a r e r e p o r t i n g f o r : 1 2 1( 1 ) S t a t e w l d e N _ e g l s t a t N e C a n d i d a t e ( 2 ) S t a t e w i d e PA C ( 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 ( 8 ) 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 po r t S l a t e o f C a n d i d a t r p

    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 ) TEL EPHONE

    Ro u t i n e Pe na l t i e s Du e F o r L a t e F i l e d Re p o r t s R a n g e f r o m $ 2 0 t o $ 8 0 0SEE I NSTRUCTI ONS ON BACK AND COMPL ETE THE FOLLOWI NGSENTENCE :

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

    [ ] CHECK I F AMENDMENT TO REPORT DATED

    0 C h e c k i f t h i s i s f i n a l ( t e r mi 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 o r m DR- 3 .( Yo u mu s t c on 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 . )

    STATEMENT OF CASH ON HANDCASH ON HAND a t t h e b e gi 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 lo f a l l mo n i e s h e l d b y t h e c o mmi t t e e . T h i s a mo u n t MUST b e t h es a m e a s t h e c a s h o n h a n d a t t h e e n d o 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 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

    ADD TOTAL MONEY TAKEN I N T HI S PERI ODS c he d u l e A: C a s h C o n t r i b u t i o n s t o t a l ( A t t a c h S c he d u l e A ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c he 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 S c he d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c he d u l e H : T o t a l Sa l e s o f Camp a i g n Pr o p e r t y ( A t t a c h S c he d u l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    ( S c he d u l e H a pp l i e s t o Ca n d i d a t e s ' Co mmi t t e e s On l v lSUB- TOTAL . . . . . . $

    SUBTRACT TOTAL MONEY SPENT T HI S PERI ODS c he d u l e B : Ex p e nd i t u r e s t o t a l ( A t t a c h S c he d u l e B ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c he d u l e F : L o a n Re p a y me n t s t o t a l ( A t t a c h S ch e du 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 a l a n ce mus tb e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ .

    1172Vd~DATE S I GN D

    I AM F I L I NGA t %CL e r ' 4 o r , 3 I l Z C 1 0 > REPORT FOR A N/ A ( 1 ) ELECTI ON / ( 2 ) NON- EL E CT I ON YEAR.I n d i c a t e o n e

    L o c a l C o mm i t t e e s , e n t e r D a t e o f E l e c t i o nCo u n t y & L o c a l C o mm i t t e e s , e n t e r Co u n t y i nw h i c h E l e c t i o n i s h e l d

    2 3 z " 3 3%351 , . o e

    t i t 8 , o q . i -z rUNPAI D BI L L S ( F r o m S c he d u l e D - A t t a c h S c he d u l e D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $I N KI ND CONTRI BUTI ONS ( F r o m S c he d u l e E - A t t a ch S c he d u l e E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ OOUTSTANDI NGLOANS ( F r o m S c he d u l e F - A t t a ch S c he d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $CANDI DATE COMMI TTEES ONLY:CONSULTANT BREAKDOWN ( S ch e du l e G At t a c he d ? ) YES V" ' NOVALUE OF CAMPAI GN PROPERTY ( F r o m S ch e du l e H - A t t a c h S c he d u l e H) $ t '. >

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    Fo r I n st r u c t i o ns , SeeBack o f Fo 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 TTEENAME( Mu s t be same a s on St a t e me n t o f Ot y a ni z a t i o n)

    ors 4C-4c-4STATECANDI DATES NOTE: I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I CA L ACT I ONCOMMI TTEE) , L I S T THEPACI DENT I F I CATI ONNUMBER AND THEPACCHECKNUMBER I N THEDESI GNATED COLUMN. A L I S TOF I D NUMBERS I S AVAI LABLE FROM THEI OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 66B. 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 ma t i o n c op i e d f r o m r e p o r t s and 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 any c omme r c i a l p u r p o s e b y any p e r 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 .

    D i s c l o s u r e l aw r e q u i r e s c a nd i d a t e commi 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 an y r e l a t i v e mak i n g a c o n t r i b u t i o n t o t h ec ommi t t e e. R e l a t i o n s h i p must be s hown 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 ) an d a f f i n i t y ( r e l a t i v e s bym a r r i a g e ) ( Se e Page 2 o f f o r ms p a ck e t . ) . I f s u r n ame o f o o n t r i b u t o r i s t h e same as c an di d a t e , b u t t h e r e i s nof a mi 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 umn .

    SUB- TOTAL

    TOTAL ( i f f a st page o f t h i s sch ed u l e )S

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    SCHEDULEA MONETARY

    ( Re v . O6 / 9 7 ) RECEI PTSQ I / CHECK T HI S BOX I F

    AMENDI NG FORM

    DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT + 1 I F FORECEI VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECEI VED FUND( MMI DDI YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SENUMBER I NCOM

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    I O f I D# ~ I I w , &-u.vASi ever5 AV ICK# 0 07 , TO,I D -, L v l I D# J e t HeW I - a - a ) ~ AceQ' rVVcK# / 7 l E0. s - 5 Mvl 4~ e i :- . c SI D3r7I D# Oe,br4- r J .. er c, " Ph l l / ~ Ps

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    Fo r I n st r u c t i o ns , See Back o f Fo r mCONTRI BUTI ONS-MONEYTAKENI N

    ( I n d 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 ds )COMMI TTEENAME( Mus t b e s ame a s o n St a t e me n t o f Or g a ni z at i o n)

    / 74I t -4STATECANDI DATES NOTE: I F A CONTRI BUT I ON I S RECEI VED FROMA STATE PAC ( P O L I T I C AL . ACT I ON COMMI TTEE) , L I S T THEPACI DENT I F I CATI ONNUMBER AND THEPACCHECKNUMBER I N THEDESI GNATED COLUMN. A L I S TOF I D NUMBERS I S AVAI LABLEFROMTHEI OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se ct i o n 68B. 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 ma 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 me nt s f o r s o l i c i t i n g c on t r i b u t i o ns o rf o r an y c omme r c i a l p u r p o s e b y an y p e r 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 es .

    SUB- TOTALTOTAL ( I f l a st page o f t h i s s c hed u l e)

    SCHEDUL EA MONETARY( Re v . =97) RECEI PTS

    CHECK T HI SBOXI FAMENDI NGFORM

    D i s c l o s u r e l a w r e q u i r e s c a nd i d a t e c ommi 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 r an y r e l a t i v e mak i n g a c o n t r i b u t i o n t o t h ec ommi t t e e . R e l a t i o n s h i p mu s t b e s hown 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 ) an d a f f i n i t y ( r e l a t i v e s b yma r r i a g e ) ( Se e Page 2 o f f o rms p a c k e t . ) . I f s u r n ame o f c o nh i b ut o r i s t h e s ame as c a n di d a t e , bu t t h e r e i s n of a mi 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 umn . ( f o r Sc h e d u l e A)P a g e

    DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT I F FORECEI VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECEI VED FUND( MMI DD/ YR) AND PACCHECK ( I f a p p l i c a b l e ) RAI SENUMBER I NCOMI D* ~Lt v/ r6/ $ ' rCK#

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