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FOR INSTRUCTIONS, SEEBACK OFFORM
DISCLOSURE SUMMARY PAGECOMMITTEE NAME(Must be same as on Statement of Organization)
O I
G1'( /41oY9412IMPORTANT: Indicate by * type of committee you are reporting f6r :( 1 )Statewide/Legislative/Judge Standing for Rete
' n Candidate ( 2 )State PAC (3 )State Party(4 )County Central Committee (5 )County Candid act
', -Candidate (7 )School Board orOtherPolitical Subdivision Candidate (8)County PAC
9
., . E
, .I
Board or Other PoliticalSubdivision PAC
11
Local Ballot Issue
Late reports are subject to possible civil and criminal penalties . Pursuant to Iowa Code section 68B.32A(7)the candidate, for a candidate's committee, and the chairperson, forany other type of committee, is theindivi
,sponsib
for filing tire* anr_pccurate reports .
SIGNATURE OF P
FLING
T
I AM FILING A
OG I ~4 01-
(l i
200-6(report date)
OCHECK IFAMENDMENTTO REPORT DATED
Check if this is final (termination) report and attach Notice of Dissolution Form DR-3.(You must continue to file reports until a DR-3 is filed .)
SUBTRACT TOTAL MONEY SPENT THIS PERIOD
7~z. a 4`6/
TELEPHONE
REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR.Indicate by # IZI
STATEMENT OF CASH ON HANDCASH ON HAND at the beginning ofthe reporting period . (Total of all funds hell 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 .) . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . $
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 Sales of Campaign Property (Attach Schedule H) . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .
(Schedule H applies to Candidates' Committe es_Only)
SUB-TOTAL . .... . . . . ... . .. . . . . .. . . $
Schedule B : Expenditures total (Attach Schedule B) ("*also see debts and bans 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). . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
"UNPAID BILLS(From Schedule D - Attach Schedule D) . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . ... . . . . . . . .. . . . . . . .. . . . . . . . .$"IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedule E) . . . . . . . . .. . . . . . . . . . . . . . . ... . . . . . . . .. . . . . . . .. . . . . . . . .. . . . . . . .. . . . . . .. .$
'"OUTSTANDING LOANS (From Schedule F - Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .$
YESCONSULTANT BREAKDOYVN (Schedule G Attached?)
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.
FORM
DR-2
I DISCLOSURE(Rev . 12/2005)
REPORT
For Office Use OnlvComm .Logged I45Scanned
Computer
Audited
File with :Iowa Ethics and CampaignDisclosure Board510 E . 12"', Ste . 1ADes Moines, Iowa 50319Fax : 515-281-3701
DATE SIGNED
Local Committees, enter Date of Election
County 3 Local Committees, enter County inwhich Election is held
29, 00
Lo, -7
29 4 0T9 .
850. ( Iy96
- NO
0
For Instructions, SeeBack of Form
CONTRIBUTIONS - MONEY TAKEN IN(Including candidate's personalfunds)
COMMITTEE NAME (Must be same as on Statement of Orgenizetion)
L-eflds7
o P L-n
orjOt'lf7STATE CANDIDATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), UST THE PAC IDENTIFICATIONNUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS ANDCAMPAIGNDISCLOSURE BOARD.
CAUTION: Section 88B.32A(8), Iowa Code, prohibits the use of information copied from reports and statements forsoliciting contributions orfor any commercial purpose by any person other than Statutory polKksll committees .
SUB-TOTAL
_ GJOtJ :-TOTAL (Nlast page of this schedule)
$Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to thethird degree of consanguinity (blood relatives) and affinity (relatives bymarriage) . If surname of contributor is the same as candidate, but there is no
Page
offamilial relationship, enter "not applicable" in the relationship column .
(for Schedu
SCHEDULEA MONETARY
(Rev. 07/03) RECEIPTS
a CHECK THIS BOX IFAMENDING FORM
DATERECEIVED
PAC ID NUMBER(if applicable)
NAME ANDADDRESS OF CONTRIBUTOR RELATIONSHIPTO CANDIDATE'
AMOUNTRECEIVED
J IF FORFUND-(MM/DD/YR) AND PAC CHECK
NUMBER(ifapplicable) RAISER
INCOMEID# q -73p p-lof,~ e. s Fo r ~o ct,~ ,A =1ff C;06 ~,CK#
MID iMo+~as~ 'a o2 IL~D ,
ID# /Vo,fy :s X -14h r-i A:~P=CK# --
ID#
- 8-4---04cK# G~~t Sh olp --ID#
cK#61~3~ ~g~t~T-'~N7
~- ~-!h , w~r~o,r"~3 d~s o~J kd S3 0
ID# 6pS~ y,~,,~ol7tirrl, +Jr' /4 K7~ ~ela~`` cK# .2,Y72- /l~l of,~.e.~.
hadpeak rPp:
r3Q'3lot s a "mss o- sID# ,~~n Lq 7-,~,atbashCK# !f/D S 44.a4A�W
et,J Y-Uvl D# g'l30 ,rap~
~pp~
~, off3s~a,
-0i WAj .AS -=4 .s-b d
ID#
~'~-16bCK# 4;i1£g yc
Sr {pcS~'lSDc araces -44 Mop
ID#~olS-~"
- Tvwaln s ?wy~ejrc f?A C'
6C&94oysl?.~' ~s~~
016 F~Sao-A ors
ID#
CK#
For Instructions, See Back of Form
CONTRIBUTIONS - MONEY TAKEN IN(Including candidate's personal funds)
COM ITTEE NAME (Must be same as on Statement of Organization),~ 1
~
a
,"H~
DYSTATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATIONNUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGNDISCLOSURE BOARD.
CAUTION : Section 88B.32A(8), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions orfor any commercial purpose by any person other than statutory political committees.
SUB-TOTAL /
TOTAL (IflastpageW fink schedule)S
Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to thecommittee . Relationship must be shown to the third degree of consanguinity (bk)od relatives) and affinity (relatives bymarriage) . If surname of contributor is the same as candidate, but there is no
Page_~offamilial relationship, enter 'not applicable' in the relationship column .
(forSchedule
SCHEDULEA MONETARY
(Rev . 07/03) RECEIPTS
Q CHECK THIS BOX IFAMENDING FORM
DATERECEIVED
PAC ID NUMBER(if applicable)
NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIPTO CANDIDATE'
AMOUNTRECEIVED
J IF FORFUND-(MM/DDfYR) AND PAC CHECK
NUMBER(if applicable) RAISER
INCOMEID#
g-iz -raC CK0
A-,OWA.) Tat.. ''c)2oID# /,-. a--(,' Aka-%4 S?q%rtfr
"Z �0c CK# AJI 24 W is-5 1',x, 200S'b iAID# /Coc& -7-%0,-'?' ps owl
4 CK# 313 E" 1S aly-w "w~~~ mar^vv
(e~,~"
ID# 4 rNd Q at- JvU4RK eu~ID# AA
,4. d, MIr S -9
CK# 3yob w RJ4
~. ~S 0bw -roL7 9o>4 1IDO
f2,41C i-wID# R2.ut M"0, 4./i1t,MCK# AFI;Z~4 1j;e a"A- A)
wTovoID# V~ t 0e-0..V\.
df7/
/;S o
wID# 4.C-/0 G wr-A
I.rarer
CK# /V Fakes U
For Instructions, See Back of FormCONTRIBUTIONS - MONEY TAKEN IN(Including candidate's personal funds)
COMMxTEE NAME (Must be same as on Statement of Orgenizefion)
tlr~~S '~ //lSTATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATIONNUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF IDNUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGNDISCLOSURE BOARD.
CAUTION : Section 88B.32A(8), Iowa Code, prohibits the use of Information copied from reports and statements for soliciting contributions orfor any commercial purpose by any person other than statutory political committees .
SUB-TOTAL
of We schedule)$
TOTAL (Iflestpage
Disclosure law requires candidate oorrsnMtess to disclose the relationship dany relative making acontribution to thecommittee . Relationship must ba shown to the third degree d consanguinity (blood relatives) and affinity (relatives. bymarriage) . If surname of contributor is the same as candidate, but there b m
Page~_of
~familial relationship, enter "not applicable" in the relationship column .
(for Schedule
)
SCHEDULEA MONETARY
(Rev. 07/03) RECEIPTS
CHECKTHIS BOX IFAMENDING FORM
DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT J IF FORRECEIVED(MMIDD(YR)
(if applicable)AND PAC CHECK
TO CANDIDATE'(if applicable)
RECEIVED FUND-RAISERNUMBER INCOME
ID# M of (j ! 7D 7
-a CK# ~~o Za -0 $
;~s--ID# JpkeL. L" - -&Dent�n Ale 1Q . e.iP
CK# l309 ..~ ~ _ .6 w "M A"J a-a }c8'
g CK# OZ/ go Al G~-~t+Qso .r
M
g'rz,~c C'ID# o4d A ~» ~.AIth 5icu
~ CK#
CK#w7-0 4)/V14 S y`er,rs
.Z It CK# /3 aAm Cb Dlv7`o r~,.T~ Sa.'to~ID# ~",~..4Ff ~hOd
g-1L-46 CK# /?-OF .6. ~p --ID# CQf`I ~I~Gtl'CK# g a lPcu.Q...+~ u
For Instructions, See Back of Form
CONTRIBUTIONS - MONEY TAKEN IN(Including candidate's personal funds)
COMMITTEE NAME (Must be same as on Statement of Orgenizedon)
All"e'hl&5 4'e -- ;frr Mo-r
R4111mt Form
STATECANDIDATES NOTE : IF ACONTRIBUTION IS RECEIVED FROM ASTATE PAC (POLITICAL ACTION COMMITTEE), LISTTHEPAC IDENTIFICATIONNUMBER ANDTHEPACCHECKNUMBER IN THE DESIGNATED COLUMN . A USTOF IDNUMBERS IS AVAILABLE FROM THEIOWAETHICS ANDCAMPAIGNDISCLOSURE BOARD.
CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of Information copled from reports and statements for soliciting contributions orfor any commercial purpose by any person other than statutory political committees .
" Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to thecommittee. Relationship must be shown to the third degree ofconsanguinity (blood relatives) and affinity (relatives bymarriage) .
If surname ofcontributor is the same as candidate, but there is nofamilial relationship, enter "not applicable" in the relationship column .
SUB-TOTAL$
ofWe schedule)$
TOTAL (lflastpage
Page of (9(for Schedule A)
SCHEDULEA MONETARY
(Rev. 07/03) RECEIPTS
CHECK THIS BOX IFAMENDING FORM
DATERECEIVED
PAC ID NUMBER(if applicable)
NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT J IF FOR(MM/DDYR) AND PAC CHECK
TO CANDIDATE'(if applicable)
RECEIVED FUND-RAISERNUMBER INCOME
1D# Y,CK# lD 4.ta W *-1 $
sa,,.at~'~_
ID# Ae, [, W : ISaK
ID# Ta R 1 4*. tk~ oGlippe'J EE1cK# D
ID#
CK#
ID#
CK# 33l
~1 Q-AAQl2-c~L cK#
a8ID# M1pR t DA
..T.*r.. s v SoID# T
r %fe CK#
ID# ~1mb~'a" Kol 9v S" ,N z3 CumA)
CK#
For Instructions, See Back of Form
CONTRIBUTIONS - MONEY TAKEN IN(Including candidate's personal funds)
COMMITTE NAME (Must be some as on Statement of Orgenizedon)"
i c~ ds
b
oY -t17
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LISTTHE PAC IDENTIFICATIONNUMBER AND THE PAC CHECKNUMBER IN THE DESIGNATED COLUMN . A LIST OF IDNUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGNDISCLOSURE BOARD .
CAUTION : Section 88B.32A(8), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions orfor any commercial purpose by any person other than statutory political committees .
Disclosure law requires candidate committees to disclose the relationship ofany relative rnaking a contribution to thecommittee. Relationship rural be shown to the third degree of consanguinity (blood relatives) and affinity (relatives bymarriage) . If surname of contributor Is the same as candidate, but there Is no
Page_.5-
offamilial relationship, enter"not applicable' In the relationship column .
(for Schedule
SCHEDULEA MONETARY
(Rev. 07/03) RECEIPTS
O CHECK THIS BOX IFAMENDING FORM
DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP -AMOUNT4
IF FORRECEIVED Of applicable) TO CANDIDATE' RECEIVED FUND-(MM/DD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOMEID#
10)
ID# YICL
0e-7* .9~ her
'ly CK# 1d13 s. Gsa
ID# a ecK#
4-- 5~aI D# /V.AR-frAl AN-.0
g~ R-QhCK# 4 0I-orlD# ~e.h tz % 5 Gk.~f'en7e.~
.~ CK# 'rID# z~,k~ot-r -Pa/s
-
CK# U, (Sox '70lT
c'~
ID# cx1, oh_ h o..{{~rp~ f~-f,Vo
lD# eCK#
2~S " ~--.,
lD# J' C, .~
cK#.s3 o k.~7~~
s
E>
For Instructions, See Back of Form
CONTRIBUTIONS - MONEY TAKEN IN(Including candidate's personal funds)
COMMITTEE NAME (Must be some as on Statement of Orgenizedon)
SCHEDULEA
I MONETARY(Rev. 07/03)
RECEIPTS
Q CHECK THIS BOX IFAMENDING FORM
STATECANDIDATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM ASTATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATIONNUMBER ANDTHE PACCHECKNUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THEIOWA ETHICS ANDCAMPAIGNDISCLOSURE BOARD.
CAUTION : Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions orfor any commercial purpose by any person other than statutory political committees .
SUB-TOTAL
TOTAL (1llastpage ofWe schedule)owI 680
Disclosure law requires candidate oommittees to disclose the relationship of any relative making a contribution to thecommittee . Relationship moa-"e shown to the third degree of consanguinity (blood relatives) and affinity (relatives by
Dmarriage) . If surname of contributor is the same as candidate, but there is no
Page-4offamilial relationship, enter "not applicable" in the relationship column .
(for Schedule
DATERECEIVED
PAC ID NUMBER(If applicable)
NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT J IF FOR(MM/DD/YR) AND PAC CHECK
TO CANDIDATE"(if applicable)
RECEIVED FUND-RAISERNUMBER INCOME
ID# ,~'q t>ra s S'0014 33 V* $
CK# S // --,ID# Mare04
yrvod C-1 tniaL4,r- "ID# L?h Z G-~+
r') CK# 0AIV055 wQLtID#
CK# S~~S 4b~SA
I D# a~ s ~, s.,~aykscK# 8 do w a Ycok A Q.ID# Yz'
12, CK#bd
ID#
_-
ID# 07cK# cT4 sM" ~sC, Dee
at' Coa LID#
1"UID# ~~ ~c+nn DA :p -~~w ~--CK# 6 Q'r'It'VJ
O yi
For Instructions, See Back of Form
CONTRIBUTIONS - MONEY TAKEN IN(Including candidate's personal funds)
COMMITTjE NAME (Must be same as on Statement of Ogi'zedon)
d JG17c1L
®
b~
STATECANDIDATES NOTE . IF A CONTRIBUTION IS RECEIVED FROM ASTATE PAC (POLITICAL ACTION COMMITTEE), LISTTHEPAC IDENTIFICATIONNUMBER ANDTHEPACCHECKNUMBER IN THE DESIGNATED COLUMN . A LIST OF IDNUMBERS IS AVAILABLE FROM THEIOWA ETHICS ANDCAMPAIGNDISCLOSURE BOARD.
CAUTION: Section 88B.32A(8), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions orforany commercial purpose by any person otherthan statutory political committees .
Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to thecommittee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives bmarriage) . If surname of contributor is the same as candidate, but there is no
Page
offamilial relationship, enter "not applicable" In the relationship column .
(for Schedule A)
SCHEDULEA MONETARY
(Rev . 07/03) RECEIPTS
0 CHECKTHIS BOX IFAMENDING FORM
DATE PACID NUMBER NAME ANDADDRESSOF CONTRIBUTOR RELATIONSHIP AMOUNT J IF FORRECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-(MM/DD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOME
4A -E $fl c
~~ ob tt_ID# .45hery# ,c~ c.. Occu .e..CK# //at :5--13ID# Ke-4(eA?
(~ CK# 7I JV f~Q+trt~
ID# L,of ,~i~~~
/tic i}7bet'?CK# E bno,)
ow peA[vID# QtS , YcK# ale
XZ>>11119ID# Yehn %S ! tC.x
~r CK# 33n
ID# ~ZOlfl¢.- w QYG
CK# lpkF Fr 4iJT~ID# g ti v
-kv,,A1 00~,
CK# ',~ DCi RZp
ID# Uac-~n,r ra, k sro/
CK# `
For Instructions, See Back of Form
CONTRIBUTIONS - MONEY TAKEN INQncluding candidate's personal funds)
CO
ITTEE NAME (Must be same as on Statement of OrganizeUon)
r.'
a -17-w li~lO'~' fl
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LISTTHE PAC IDENTIFICATIONNUMBER AND THE PAC CHECKNUMBER IN THE DESIGNATED COLUMN . A LIST OF IDNUMBERS IS AVAILABLE FROMTHE IOWA ETHICSAND CAMPAIGNDISCLOSURE BOARD .
CAUTION : Section 6BB.32A(B), Iowa Code, prohibits the tss of Information copied from reports and statements for soliciting contributions orfor any commercial purpose by any person other then statutory political committees .
Disclosure law requires candidate oommittees to disclose the relationship of any relative nmqkIng acontribution to thecommittee . Relationship mast be shown to the third degree of consanguinity (blood relatives) And affinity (relatives by
Omarriage) . H surname of contributor is the same as candidate, but there is no
Page-
offamilial relationship, enter "not applicable' In the relationship column.
(for Schedule;%)
SCHEDULEA MONETARY
(Rev. 07/03) RECEIPTS
Q CHECK THIS BOX IFAMENDING FORM
DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT ,1 IF FORRECEIVED (d applicable) TO CANDIDATE" RECEIVED FUND-(MM/DD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOMEID# A IRA) Da 4"
g la7 ~~o CK# d1 o3-/-4.9 Avos, S Ci/" --r wiv4 ddo
ID# V-cf7"a 41~"Artc~CK# //ow APT 3 /I
. c, AJTo !! .T~4'S~o o?D r'ID# abro4'k
CK# 56ID# ' k.rh Ro SS
~~S oID#
.210 10 1;NawTv0 Xa so''a~
1D# (plc - tort /VioRJ7ovdCK# rdfs -r4arnas qt'e KeWS* a
A C JAVa Zc-.srV XspID# Jrye-an %+.c LanhPNt
-PO ~IL CK# S«~/Fos~~ DeDes NW-pt &
ID# 8fe.-rrA . 7~&hnAtjCK# rlr j`d ;trv 9A
tv0, .7-L490- >.DrIDO 1N1 +~iM~ S ~ot~lQ-rfL
&.,rs Tr.
G~G CK# 9?s: 60 Ave.so
,&�610A X-'a- SID# t&4'm
G-'~ /-,pG cK#K~.,,v"fb S-b .-J~
For Instructions, See Back of Form
CONTRIBUTIONS -- MONEY TAKEN IN(Including candidate's personal funds)
COMMITTEE NAME (Mustbe same as on Statement ofOrganization)
re, 44"~f aI
Pk rjew aq
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATIONNUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGNDISCLOSURE BOARD.
NOTE : ANY PERSON, OTHER THAN AN INDIVIDUAL, THAT CONTRIBUTES MORE THAN $750 TO YOUR CAMPAIGN MAY HAVE FILINGRESPONSIBILITIES AND SHOULD IMMEDIATELY CONTACT THE BOARD.
CAUTION : Section 68B.32A(6), prohibits the use of information copied from reports and statements for soliciting contributions or for anycommercial purpose by any person other than statutory political committees.
Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to thecommittee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by
Omarriage) .
Ifsumarne ofcontributor isthe same as candidate, but there is no
Page ,
,- offamilial relationship, enter "not applicable" in the relationship column .
(for Schedule A)
SCHEDULEA MONETARY
(Rev . 07/03) RECEIPTS
CHECK THIS BOX IFAMENDING FORM
DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT 4 IF FORRECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-(MM/DD/YR) AND PAC CHECK
NUMBER(if applicable) RAISER
INCOMEID# LA, ; awt ~altMa-
'r ('a6 CK# 9l3 w " j ~t,J,~'v2o8" lv0
1'j('o6ID#
CK#
"zo /V- - E. 0u_ro -2s-:oo
q'Iz-OilID# ~f'
6'4iY&177A
0, Fct~'nJ,
~`ds~i~2 r 274 CS L4-01~CK# boo .ad
ID#
l l -o~ CK# 177.2 1Z c, _ 0''ly ~ 0 inil~
ID#1as151a ,- w- hrabjiZA, 6""1r4,f alrt .
f-0 - 80 10 2J-0 . 0CIV" 2--A ~~Ir
-.~ /- DZ7 4f~
CK# 3Sr~~~7rAV~
~f~ftZ P,¢2_~-0o. oo Ald ..) 4-r- , y Y /D 17
ID#perltnY ,R , osiol-K-
CK# loot 9 S- o9,- LA)
ID# 7 .705- -?4¢,
<Ar7OM P.¢G . wG
Ai ,4 vID#
~-2 0;6 CK# 14166 /1 A St -SW
A - ~7., o00ID# l&ywvand 4 A*tc1d-tTorL
~.ZF-0tp CK# -Z1 ~ r ji"~bt v°eTi~ .Dr-,_
Sl"! 4L, -6-000.9
For Instructions, See Back of Form
CONTRIBUTIONS - MONEYTAKEN IN(Including candidate's personal funds)
COMMITTEE NAME (Must be same as on Statement ofOrganization)
rr;MA of -rim aor4
h
RosatFat=
STATE CANDIDATES NOTE: IFACONTRIBUTION IS REC1IVED FROM ASTATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATIONNUMBER ANDTHE PACCHECKNUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROMTHEIOWA ETHICS ANDCAMPAIGNDISCLOSURE BOARD.
CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions orfor any commercial purpose by any person other than statutory political committees .
Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to thecommittee. Relationship must beshown to thethird degree ofconsanguinity (blood relatives) and affinity (relatives bymarriage) .
Ifsurname of contributor is the same as candidate, but there is no
Page
(0
offamilial relationship, enter "not applicable" In the relationship column .
(for Schedule A)
SCHEDULEA MONETARY
(Rev . 07/03) RECEIPTS
CHECKTHIS BOXIFAMENDING FORM
DATE PAC ID NUMBER NAME ANDADDRESSOF CONTRIBUTOR RELATIONSHIP AMOUNT J IF FORRECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-(MM/DO/YR) ANDPAC CHECK (if applicable) RAISER
NUMBER INCOMEID#
10-( -04 CK# ft%/0 .vQ z . $~d -Oo~o
l D# W 63" F
10-(0-06 CK# boo -5 _4 ~ . o0
la-(o -o.6ID#
s q~ s NYCK#
ID# Kt n'f1/0~!Z~o 6 CK# /7 sf .s-w
.~vo0 .20-00AID# 4lao'-I i Sfov4 Il
1=0:r4a6ac' (114 20 1ID# fcofl" ~ Ske, L,er;G`-a,KcP
Do0ID# Cr i C. ~Ol'S~^~ L1,CK# iri .i s-t- - s S0 .cam
o0oID# -
(0_Q-0(, CK# u~la ;-Fort . 2.e~( t~t-~ ,dk f .Za . ~c
ID#
CK#
ID#
CK#
THIS BOX APPLIES TO CANDIDATES' COMMITTEES OILY:
Purchases of certain campaign property costing i500 or more must also be inventoried on Schedule H . (Refer to Schedule H instructions.)
Expenditures to persons/entitles providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized onSchedule G bythe amount, purpose, and data ofeach type ofexpenditure made by the person/entity on behalf of the candidate's committee . (Refer toSchedule G Instructions and Iowa Code 88A.A02(3)(i).)
(for Schedule B)
FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
EXPENDITURES B MONETARY- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev . 07/03) EXPENDITURES
STATE PAC COMMITTEES: NOTE: FOR CONTRIBUTIONS MADE TOSTATEWIDE OR LEGISLATIVECANDIDATES, LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE D CHECKTHIS BOX IFPAC CHECK NUMBER FOR EACH EXPENDITURE. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORMETHICS & CAMPAIGN DISCLOSURE BOARD.
COMMITTEE NAME (Must be Same as on Statemen ofOrgenizedon)
7r~i .e4, A 64 rm (Q r' QI-vCANDIDATE NAME AND ADDRESS YO WHOM PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDEDEXPENDED (if applicable) (Disbwasmenh WAS MADE(MM/DD(YR) AND PAC
CHECKNUMBER
ID#
7-l7-d~ CK#
?-11-0L CK#'~~~
,e-' 1 .~ / (Tha.~ic, Cdr' Siikts 24M-~02v
74q-06 CK# l SS .rA .3`ozo Sit, ; ~ ~aID#
IIF=0,6 CK# ll~ wZ="~SfiAl . Lgbe~S ~~i~S5.6 N _57b)c>
~.s P1?1~-06 CK# lost .2ISS .Z "=/ A''z -~ ~ff5
ID#Pl-iL~f"
11 .2Z3c~i-~~
St- L4 4a-6 '~ ~0i2f S OCK#
l~s- ~
o..u IZA
CK#
LAY1:~ 7. r7
. 1~ O d 1~'v i fafloaI D# ~or~ ~cci~ pYl~'Lt
-(-o,6 CK# /17 S . ,~. 7~-la6o
SUB-TOTAL $ 7q5-, 36
TOTAL (lf Isstpage ofdNs schedule) $
THIS BOX APPLIES TO CANDIDATES' COMMITTEES ONLY:
Purchases of certain campaign property coating $500 or more must also be inventoried on Schedule H . (Refer to Schedule H instructions .)
Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing services mustalso be detail itemized onSchedule G by the amount, purpose, and date of each type of expenditure made by the person/entity on behalf of the candidate's oornmittee. (Refer toSchedule G instructions and Iowa Code SaA.402(3)(i) .)
Page
2
of-
(for Schedule B)
FORINSTRUCTIONS, SEEBACK OF FORM ( SCHEDULE
EXPENDITURES B MONETARY- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev. 07/03) EXPENDITURES
STATE PAC COMMITTEES : NOTE : FORCONTRIBUTIONS MADE TO STATEWDE OR LEGISLATIVE D CHECK THIS BOX IFCANDIDATES, LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THEPAC CHECK NUMBER FOR EACH EXPENDITURE . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORMETHICS d CAMPAIGN DISCLOSURE BOARD.
COMMITTEE NAME (Must be same as on Statement ofOrganization)
[At r q tt"
CANDIDATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNTDATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDED
EXPENDED (if applicable) (Dwbrnsemerrh WAS MADE(MWDDYR) AND PAC
CHECKNUMBER
ID# f/ -Oa x-
rot(0461 ti 1o az~
ID# td,,--A A n '/-"
CK# 1201 A/- 'VZV/G-,'~-(06), A4W4-)., s
ID# co I.~.e rta'~QrC K
CK# r0 r M q'Y4 ilTrI~b,OQ-3 fw- whvl7 4Tr J10,6 Lx--t 1 ( A
fY-3 "Ob CK# ~p6,~ l ~ 7 w a'"' Sfi . - Pvih ~" V i1-4 46 1j~
ID#
g3-~o cK#2(S-Sa",~AvS- F, _r4'e p
ID# rar"ies o1 Tic2 ,rr NIA( ,-016 cK# N- .2 'd AoQ 7t
l 6.6 ,vID#
/.x-06 CK# itl P~i-4tk eA4y ,10167 . 1:~t
ID# ac~G-47CD .
~d' ~GffCK#loi;Jl%r Av- - 0 . c~w'K-faz' _O
oSUB-TOTAL $
TOTAL ofIrst page of this whedule) $
THIS BOX APPLIES TO CANDIDATES' COMMITTEES ONLY:
Purchases of certain campaign property costing $500 or more must also be inventoried on Schedule H . (Refer to Schedule H instructions.)
Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing serves must also be detail itemized onSchedule G by the amount, purpose, and date of each type ofexpenditure made by the person/entity on behalf of the candidate's committee . (Refer toSchedule G instructionsand Iowa Code BBA.402(3)(Q .)
Page
9of _� 4
(for Schedule B)
FOR INSTRUCTIONS, SEEBACK OF FORM SCHEDULE
EXPENDITURES B MONETARY- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev . 07/03) EXPENDITURES
STATE PAC COMMITTEES: NOTE : FORCONTRIBUTIONS MADE TOSTATEWIDE OR LEGISLATIVECANDIDATES, UST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE CHECK THIS BOX IFPAC CHECK NUMBER FOR EACH EXPENDITURE . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORMETHICS & CAMPAIGN DISCLOSURE BOARD.
COMMITTEE NAME (Must be same as on Statement ofOrgenization)
6-iaAJ5 0 ~ i ~o r I vvCANDIDATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDEDEXPENDED (if applicable) (Dlsbtrtasrnerro WAS MADE(MM/DD/YR) AND PAC
CHECKNUMBER
ID# Ny~V,u ~r%C~s7Dre. rn raC~'SS+n.
&4 CA/Qu! S.~ i ~cf~ ".ra~ ~R i
ID# /<ei-fl, Nf)3-06 CK# /(/I A&dd Pb'ilicq l Cojtj4+i' l ~Os' y-S
1070 26 o- ~A SodID#
F-.23-P6 CK# IM¢ o~ Iowa ~~~~~ Ciw1 jt~ 00 00107
fQ3-C6ID#
CK#
op pi,lhf l4.261& Par.-/c e . ~~,Jik~ss ~.wp~5 7y 4fla7ZMu e4 ihg S .x.276
ID#o P PY7ilfl~ .7
TQ3-0f- CK# -Z61b At+ ,* Ae.-107 M rye rA 5 7
7-106
ID#
CK#
ll~~ ,fvl-Y ~kf~+' ris ~SS.zoo f.w .
)o-t.S-leo7 Ve~
wlI!rh~y P,~ptrQyr,,(071u
ID#1,+16Kja P lot,n1--
CK# 1109 Al . qA *e_W. *stirrli-4 k;r , e,Ass; f--,4-f- 1600 .0t
1,.s-o6 CK# l2 01 N' Y ,ova. u) ,of~i~2. J ~o~i2Jsa
SUB-TOTAL
i
$ .2j,01_
TOTAL (lost~ of this schedule) $
THIS BOX APPLIES TO CANDIDATES' COMMITTEES ONLY :
Purchases of certain campaign property costing SS00 or more must also be inventoried on Schedule H . (Refer to Schedule H instructions.)
Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized onSchedule G by the amount, purpose, and daft ofeach type ofexpenditure made bythe person/entity on behalf of the candidate's committee . (Refer toSchedule G instructions and Iowa Code SW402(3)(i).)
b
(for Schedule B)
FOR INSTRUCTIONS, SEE BACK OF FORM Rom SCHEDULE
EXPENDITURES B MONETARY- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev . 07/03) EXPENDITURES
STATE PAC COMMITTEES: NOTE : FOR CONTRIBUTIONS MADE TOSTATEWIDE OR LEGISLATIVECANDIDATES, LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE D CHECKTHIS BOX IFPAC CHECK NUMBER FOR EACH EXPENDITURE . A LISTOF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORMETHICS 3 CAMPAIGN DISCLOSURE BOARD.
COMMITTEE NAME Mustbe same as on Statement ofOrganization)
'4 7--ioL MrVZa-1--CANDIDATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDEDEXPENDED (if applicable) (DfWr"trnerrq WAS MADE(MWDDYR) AND PAC
CHECKNUMBER
CK# /077 JaI IsTJ--t . A,/ , $ 9 00
,4.s-0
oID# cps PsCK# .z 1-5- -r .a V-pAve. F. Pos-~4~ e, ss-`
l0 7j, /V" r"4 S17ID# Iro r6 t-s 0 ,,;c k
-d=o6 CK# 0 71 I 1 ~W- a '='4 SfsZo C~7~ s ?_0.6
ID# VOok-Y E;ffffl-r viSaS_
CK# s2,co T.W. 3o -J4- 7 6441e- Tu ?b ,k So~od0 ~~~ oI- _'~ S.z o
ID#hs PS
CK# lot I Its- s' .
iD#Law 'S .Sf~vl ~°Sff d-
9-(3'ob CK# .~6ro ~' sf-S.w2 s; l 77-~-Z
to~~
s ~s {z)- hs.D#
to 5
iD# f~~s o.~fry. ~kr ~fc7-4-o6 cK# l oft /0Z N1 w2-
Salt_ -
SUB-TOTAL $ 6TOTAL (IfAsst page ofthis schedule) $
THIS BOX APPLIES TO CANDIDATES' COMMITTEES ONLY:
Purchases of certain campaign property costing $500 or more must also be inventoried on Schedule H . (Refer to Schedule H instructions .)
Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing services mustalso be detail itemized onSchedule G bythe amount, purpose, and date of each type of expenditure made by the person/entity on behalf of the candidate's committee . (Refer toSchedule G instructions and Iowa Code 611A .402(3)() .)
Page
-5-
. of
(forSchedule B)
FOR INSTRUCTIONS, SEEBACK OF FORM SCHEDULE
EXPENDITURES B MONETARY- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev. 07/03) EXPENDITURES
STATE PAC COMMITTEES: NOTE : FORCONTRIBUTIONS MADE TO STATEWIDE OR LEGISLATIVECANDIDATES, LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE D CHECK THIS BOX IFPAC CHECK NUMBER FOR EACH EXPENDITURE . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORMETHICS d, CAMPAIGN DISCLOSURE BOARD.
COMMITTEE NAME (Must be same as on Statement ofOrganizedon)
`%QMGCs o-F ~ M,9, I-- 9 wCANDIDATE NAME AND ADDRESS TO WHC)M PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDEDEXPENDED (d applicable) (Diabursemeno WAS MADE(MWDD/YR) AND PAC
CHECKNUMBER
iD# oftT(qo6 CK# -9oDC,i~sifYQ-~M~4x
+ SMati ~ . (r'tvtvrr~fiokf $
ID# (4sPs7;zo-o6 CK# ~IS-, ~"~~ o . ~oj4t2- ~ 5A-"1-5 /.2 s:3sto~~
iD#~or6QS aLU~k
Z2-o6 CK# f~7 w.1 .St. IV- Prig1D# vw 5~.~~
S~117 S.r L~ewa, VA D,1,
iD# ff.~ .co tw
TZ06 CK# i ~ ~9 S.2oo Y- (A) 30-124 52
7-43r-ob
1D#
CK# '~~~~ far (~r v~ D; rQCF mG1 j 12, 7?,6.6X/o a Mr..sc4 frhc 5-276
ID#OP P`--1h -f`7
10 -1-0 CK# l01o261& Ne(c
-54 S-2761D# A4-01^ Co .
1!Z3 /-~r Ana-,MAt7~"
F- S~`PPl- ,~ 'h~f1 !S1 -2 d'
CK# /oq
y s-008'SUB-TOTAL
TOTAL (Mist page of this schedule) $
THIS BOXAPPLIES TO CANDIDATES' COMMITTEES ONLY :
Purchases of certain campaign property costing $500 or more must also be inventoried on Schedule H. (Refer to Schedule H instructions .)
Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized onSchedule Gby the amount, purpose, and date of each type of expenditure made by the person/entity on behalf of the candidate's committee. (Refer toSchedule Ginstructions and Iowa Code 68A.402(3)(i) .)
Page-of
(forSchedule B)
FORINSTRUCTIONS, SEEBACK OF FORM R~FOMl- SCHEDULE
EXPENDITURES B MONETARY-MONEY SPENT FROM COMMITTEE ACCOUNT (Rev. 07/03) EXPENDITURES
STATE PACCOMMITTEES : NOTE : FORCONTRIBUTIONS MADE TO STATEWIDE OR LEGISLATIVECANDIDATES, LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE CHECKTHIS BOX IFPAC CHECK NUMBER FOREACH EXPENDITURE. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORMETHICS 3 CAMPAIGN DISCLOSURE BOARD.
COMMITTEE NAME (Must be same as on Statement ofOrganization)
fki114V, -77~i / (M-Y-42o
CANDIDATE NAME ANDADDRESS TO OM PURPOSE AMOUNTDATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDED
EXPENDED (if applicable) (Disbursement) WAS MADE(MM/DD/YR) AND PAC
CHECKNUMBER
ID# Lt/ o4,wrtza? iv- qt/4-a, . w. l N,t~,rs~r-y-~~~ ~1-ss~S n~' $ IoGY~ .oc~CK#~ o~
sbzoID#
Can~'
_
/TwovfiSf '~ `TDCK# '+tl C-avrcH.tawlagID#
CK#
ID#
CK#
ID#
CK#
ID#
CK#
1D#
CK#
ID#
CK#
SUB-TOTAL $ lqo -00TOTAL (Iflast page ofthis schedule) $29, 05'1- o
FOR INSTRUCRONS, SEE SACK OF FORM
COMMITTEE NAME (Mustbe same as on Statement of Organization)
I ~
o
TN2 / Cow 2w
NOTE: Debts previously reported that remain unpaid must
included on thisSchedule, aswell as any new obligations incurred in this period . Pima Fam
SCHEDULED INCURRED
(Rev . 0&98)1 INDEBTEDNESSaCHECK THIS BOXIF AMENDINGFORM
An "incurred debt" is a debt forDEBTS/OBLIGATIONS REMAINING THIS REPORTING PERIOD
goods or services ordered or(DO NOT INCLUDE LOANS - SHOW LOANS ON SCHEDULE F)
received, but rat paid for by theend ofthe reporting period .,regardless ofwhether an invoicehas been received
`If actual figure is unknown, show"estimated" beside the figure .
Page
of(for -Schedule)
CANDIDATE COMMITTEES NOTE:'Incurred indebtedness also includes each persontentity with whom the ca,xiidato's committee has entered into a contract during the reporting period for futureor continuing performance . Enter the name of the consultant who provides or procures services for items such as advertising, fund-raising, polling, managing, ororganmng services . Report on Schedule G the nature of performance and the estimated performance reasonably expected of the consultant .
DATEINCURRED(MM/DDYR)
NAME AND ADDRESS OF PERSONTO WHOM DEBT OR OBLIGATION IS OWED
DESCRIPTION OFGOODS ORSERVICES PROVIDED OR
PURCHASED
BALANCE OWED ATCLOSE OFREPORTINGPERIOD'
l03- 0,6 S2no TV ~!-~P p~odu~foti- 7 0 .do
10-6 -06Vi ~'+f
5:z0L{Uh~
a s-Id - ,~ ZI of oz
A~*a fglqGwpa eAl 70-(l
SUB-TOTAL $
TOTAL DEBTS OWEDBY COMMITTEE AT THE END OF THIS REPORTING PERIOD $
FOR INSTRUCTIONS, SEE BACK OF FORM
COM 17TEE NAME (Mastbesame ason StatementofOrgankatfon)
o
Ti'vLt MoaQPL,-
SCHEDULEE IN-KIND
(Rev . 0619T/ CONTRIBUTIONS
CHECK THIS BOX IFAMENDING FORM
'Disclosure law requires candidates to disclose the relationship ofany relative making an In kind contribution to thecommittee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives
(for Schedule E)by marriage). (See Page 2of forms packet.) If surname of contributor is the same ascandidate, but there is nofamilial relationship, enter"not applicable" in the relationship column .
DATERECEIVED(MMIDD(YR)
NAME ANDADDRESSOF CONTRIBUTOR
RELATIONSHIPTO CANDIDATE' (if applicable)
DESCRIPTIONOF IN KIND
CONTRIBUTION
ESTIMATEDFAIR MARKET
VALUE
IF FORFUND-RAISERCONTRIBUTION
Cry-+ 41+- &-ASeA-(J' VOhGY
l_ Lqv-rl~wos Ca >~~~ d ~wS
-?1I?
~3`0~R~~
u.6(Z&h P, ~'l E as t 9
~(,rh .~'q .30 oLetYR+- wrf
saz,rc c .2 'D (~ FF-1F-1F-1F-1F7F-1F-1F7
FOR INSTRUCTIONS, SEEBACK OF FORM
COMMITTEE NAME(Mustbe some as on Statementof Organization)
ro 44'jj o~ T4 /t10,'-7"-PART 11- ITEMIZED BREAKDOWN OF UNREIMBURSED EXPENSES PAID BY CONSULTANTTO OTHERS IN PERFORMING SERVICES OF CONTRACT (These expenses should NOT be
PART 1- NAME AND ADDRESS OF CONSULTANT
reported on Schedule B, as they are direct payment from the consultant.)
Name ofCons tant
Mailing Address
City
ESTIMATES OF PERFORMANCE
State
~~ ~v 1 h2S
-Lower
TOTAL ANTICIPATEDCOMPENSATION FOR
CONTRACT PERIOD (MMIDD/YR)
PERFORMANCE
Zip Code
sa.2or
From 7-12-0d
Reset Form
Page ( of-j(for Schedule G)
SCHEDULE
G BREAKDOWNOF MONETARY
(Rev .02/96) EXPENDITURESBY CONSULTANT
L CHECK THIS BOX IFAMENDING FORM
DATEEXPENDEDMM/DO/YR
NAME AND ADDRESS TO WHOM EXPENDITURE(Disbursement) WAS MADE PURPOSE
AMOUNTEXPENDED
s
SUB-TOTAL
TOTAL (If last page of this schedule) $