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FOR I NSTRUCTI ONS, SEE BACK OF FORM

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nCHECK I F AMENDMENT TO REPORT DATEDr l C 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 o r m D R - 3 .( Y o u mu 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 . )

STATEMENT OF CASH ON HAND

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Ro u t i ne P e n a l t i e s Du e Fo r L at e F i l e d Re p or t s Range f r o m $ 2 0 t o $ 8 0 0SEE I NSTRUCTI ONS ON BACK AND COMPLETE THE FOL L OWI NG SENTENCE

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CASH 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 lo f a l l mo n i e s h e l d b y t h e c o mm i t t e e T h i s a m o u n t MUST b e t h es ame 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

FORMDR- 2 D I S C L OS U R E( R e v . 0 1 / 9 8 ) IREPORTL o c a l C o m m 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 8 L o c a l C o m m i t t e e s , e n t e r C o u n t y i nw h i c h E l e c t i o n i s h e l d

ADD TOTAL MONEY TAKEN I N T H I S PERI ODS c h e 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 h e d u l e A ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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Fo r I n s t r u c t i o n s , Se e Bade o f F o 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 pemona l f u n d s )COMMI TT EENAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i o n )Pe0

SCHEDULEA MONETARY( Re v . U 6 1 9 7 )

RECEI PTS

CHECK T HI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE: I F ACONTRI BUTI ON I S RECE I VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) . L I S T THEPAC I DENT I F I CATI ONNUMBER ANDTHEPAC CHECKNUMBER I N THEDESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LABLE FROM THEI OWA ETHI CSANDCAMPAI GNDI SCLOSURE BOARD.CAUTI ON : Se c t i o n 68B. 3 2 A ( 6 ) , I o wa Cod e , p r o h i b i t s t h e use 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 r i b u t i o n s o rf o r an 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 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 .

DATE PAC I D NUMBER NAMEANDADDRESS OF CONTRI BUTOR RELA T I ONSHI P AMOUNT J I F FORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-

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3/25

Fo r I n s t r u c t i o n s , See Back o f Fo r mCONTRI BUTI ONS - MONEYTAKEN I N

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STATECANDI DATES NOTE: I F A CONTRI BUT I ON I S RECEI VED FROM ASTATE PAC ( P OL I T I C A L ACT I ON COMMI TTEE) , L I S T THEPAC I DENT I F I CAT I ONNUMBERANDTHEPACCHECKNUMBER I N THEDESI GNATEDCOLUMN . AL I ST OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON: Se c t i o n 68B . 3 2 A ( 6 ) , I o wa Co d e, p r o h i b i t s t h e u se o f i n f o r mat i o n c o p i e d f r o m r e p or t s an 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 r i b u t i o n s o rf o r an y c o mme r c i a l p u r p o s e b y any p er s o n o t h er 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 .

SCHEDULEA MONETARY( Re v . 0 6 1 9 7 ) RECE I PTS

CHECK T HI S BOX I FAMENDI NGFORM

DATE PAC I D NUMBER NAMEANDADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT d I F FORRECEI VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECEI VED FUND-( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOME

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4/25

Fo r I n s t r u c t i on s , See 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 a s o n S t a t e me n t o f O r g a n i z a t i o n )Peopl e - ~) r VY) ac. , y .

SCHEDULEA MONETARY( Re v . 0 6 / 9 7 )

RECEI PTS

E] CHECK T HI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE: I F A C ON T RI B U T I ON I S R E CE I V E D FROM A STATE PAC ( P OL I T I C A L A C T I O N C OMMI T T E E ) , L I S T THEPAC I D EN T I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N T HE DESI GNATED COL UMN . 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.CAUTI ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa 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 i o n s o rf o r a n y c ommer c i a l p u r p os 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 .

DATE PAC I D NUMBER NAMEANDADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT J I F FORRECEI VED ( f f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-( MM/ DD/ YR) AND PAC CHECK ( I f a p p l i c a b l e ) RAI SERNUMBER I NCOME

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5/25

Fo r I n s t r u c t i o n s , Se e Ba c k 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 )1117MI TTEENAME ( Mus t b e s ame a s o n S t a t eme n t o f Or g a ni z a t i o n)

SCHEDULEA

I MDNETARY( R ev . o & s 7 )

RECEI PTS0CHECKT HI S BOX I FAMENDI NG FORM

STATECANDI DATES NOTE: I F ACONTRI BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ONCOMMI TTEE, L I ST THEPAC I D ENT I F I C AT I ONNUMBER ANDTHE PACCHECK NUMBER I N THEDESI GNATED COLUMN. A L I S T OF I D NUMBERS I S AVA I LABLE FROM THE I OWA ETHI CS ANDCAMPAI 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 a nd s t a t e me nt 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 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 i t i c a l c ommi t t e e s .

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR R E LAT I ONSHI P AMOUNT J I F FORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECE I VED FUND-

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6/25

Fo r I n s t r u c t i o n s , Se e Ba c k o f F o 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 )CQMMI TTEENAME( Mu s t be same a s o n S t a t e me n t o f Or g ani z a t i o n)420, P-&r rmaa,k.

f o r a n y c omme r c i a l p u r p o s e b y an y p er 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 .

STATECANDI DATES NOTE: I F A CONTRI BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACT I ON COMMI TTEE) , L I S T THE PAC I DENT I F I CATI ONNUMBER AND THEPAC CHECKNUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se ct i o n 6 8B . 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 pi 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 o n t r i b u t i o n s o r

SCHEDULEA MONETARY( R ev - 0 6 / 9 7 ) RECEI PTS

0 / CHECKT HI S BOX I FAMENDI NGFORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT J I F FORRECEI VED ( f f a p p l i c a b l e ) TO CANDI DATE` RECE I VED FUND-( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI S ERNUMBER I NCOME

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7/25

Fo r I n s t r u c t i o n s , Se e Back o f F o r t hCONTRI BUTI ONS - MONEYTAKEN I N

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18/25

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 )I C MI TTEENAME( Mus b e s a r n e a s o n St a t e me n t o f Or g a n i z a t i o n)IQo0~e- iuvMa- -

1 3STATECANDI DATES NOTE: I F ACONTRI BUT I ON I S RECEI VED FROMASTATE PAC( P OL I T I C A L ACT I ON COMUI TTEE~ L I S T THE PACI DENT I F I CAT I ONNUMBER AND THEPACCHECKNUMBER I N THEDESI GNATEDCOLUMN . AL I S T OF I D NUMBERS I S AVAI LABLE FROMTHEI OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD.CAUTI ON: Se c t i o n 68B . 3 2 A ( 6 ) , I o wa Co d e, 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 on c op i e d f r o m r e p or 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 nt r i b u6 on s o rf o r an y c o mmer c i a l p u r p os e by 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 .

SCHEDULEA MONETARY( Re v . 0 6 1 9 7 ) RECE I PTS0CHECK THI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT d I F FORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE ' RECEI VED FUND-( MMI DD1YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOME1b I b I D# d r ' ~ c . Su ~dk A- k ~ J f h eC- 1ek 0wArCK# ~D4 U0 , , c l - - e - V 9 ~ ; L o i S- 3 g - a : 7 o ZDI ~

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19/25

Fo r I n s t r u c t i o ns , Se e Back o f Fo r tCONTRI BUTI ONS - MONEYTAKEN I N

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f o r any c o mmer c i a l p u r p o s e by an y p er s o n o t h er 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 .

SCHEDULEA MONETARY( Re v . M97)

RECEI PTS

CHECKT HI S BOX I FAMENDI NGFORM

STATECAN DATES NOTE: I F ACONTRI BUTI ON I S RECEI VED FROMASTATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) . L I S T THEPAC I D EN TI F I C AT I ONNUMBERANDTHEPACCHECKNUMBER I N THEDESI GNATED COLUMN . AL I S TOF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CSANDCAMPAI GNDI SCLOSURE BOARD.CAUTI ON: Sec 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 o p 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 r

DATE PAC I D NUMBER NAMEANDADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT J I F FOR

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20/25

Fo r I n s t r u c t i o n s , Se e Ba c k o f F o r mCONTRI BUTI ONS - MONEYTAKEN I N

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SCHEDULEA MONETARY( R ev . W97)

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RECEI PTS

CHECKTHI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I F ACONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I ST THEPAC I DENTFCATI ONNUMBERANDTHEPAC CHECKNUMBER I N THEDESI GNATED COLUMN. A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA ETHI CS ANDCAMPAI 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 us e o f I n f o r ma t i o n c o pi e d f r o m r e p o r t s an 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 nt n bu t i o ns o rf o r an y c omme r c i a l p u r p o se 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 ommi t t e e s .

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21/25

FOR I NSTRUCT I ONS , SEEBACK( ORM SCHEDULEEXPENDI TURES B- - MONEY SPENT FROM COMMI TTEE ACCOUNT MONETARY( R e v . 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUT I ONS MADE TO STATEWI DE OR LEGI SLAT I VECANDI DATES . L I ST THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE El CHECK T HI S BOX I FPAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD.COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i o n)peo

~ ,V

CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE( MM/ DDI YR) AND PACCHECKNUMBER

1 D# p VC +eV' A _ i I- r t GC N ~ -r ec ~ ( J r ~ D~c K#F)6" ' ~z . ~ o a d $ t ea ` 9 , 7 4I D# 'I I ( 4 1 J a m - , ~ -CK# s ~ 3

d0' Qar \ l , 1 0 3 0 1CK# r n t i l 5 5Y 3 b t 7 II D#6 1 CK#

I D#/ ~ -

I D#


22/25

FOR I NS TRUCT I ONS , SEE BACK, =ORM SCHEDULEEXPENDI TURES B- - MONEY SPENT FROMCOMMI TTEE ACCOUNT MONETARY( Re v . 0 9 1 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE T O STATEWI DEOR L E GI S L A T I VECANDI DATES, L I S T THE CANDI DATE I DE NT I F I CA T I ON NUMBER I N THE DESI GNATED COLUMN AND THE E E I CHECK T HI S BOX I FPACCHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVA I L AB L E FROMTHE I OWA AMENDI NG FORME T HI CS & CAMPAI GN DI SCLOSURE BOARD .COMMI TTEE NAME ( Mus t be s ame a s o n St a t emen t o f Or g a ni z a t i o n )QL ( ~ ~ e - ` ~MG~C-~_

CANDI DATE NAME ANDADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BETRANSACTI ON) EXPENDEDEXPENDED ( i f a pp l i c a bl e ) ( Di s b u r s e me n t ) WASMADE( MM/ DDI YR) ANDPAC

CHECKNUMBER

1 0 1 I D # ~1 7 i o O - 1c K# 1 ~ ~ o l g $ C~ ~ ( o , L I - 7I D #

1 7 Pv Q) C~ * 13o lCK# 96~ 7?! U e , 5 f 3 -OoI O' a I l

I D # I ~ c -CK#I I I D# - ~-

I i ( o 3. L 4 04 - )I D# U,

I t o~bV Pv I ^ F 30 1CK# ~ Us - - v n o ,

( I I D# ' _ t 1 4- a JIAA' -_PU ~c~- 1 ` l ~ 7CK# f


23/25

FOR I NS TRUC I I ONS, SEE BACK OF FORM


24/25

" 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 mmi 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 a n y r e l a t i v e"

ma k i n g a c o n t r i b u t i o n t o t h e c o mmi t t e e R e l a t i o n s h i p mus t b e s h o w n 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 i n i t y ( b l o o d 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 ma r r i a g e ) ( S e e P a g e 2 o f f o r msp a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e s a m e 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 i l i 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 mn w h e n i t a p p l i e s

COMMI TTEE NAME( Mus t b e s a r n e a s o n S t a t e me n t o f Or g a n i z a t i o n )ma ~Q2CPj e_ .

NOTE T h i s s c h e d u l e r e p o r t s m o n e y l o a n e d t o t h e c o mmi t t e e w h i c h i s d e p o s i t e d i n t h e c o mmi t t e e a c c o u n tTOTAL UNPA I D LOANS FROMLASTREPORTI NG PERI OD $ - - ( f ) . OOPART I - MONETARY LOANS RECEI VED_THI S REPORTI NG PERI OD( O r i g i n a l s o u r c e o f l o a n , s u c h a s a b a n k , mu s t b e s h o w n i t a t h i r d p a r t y i s

i n v o l v e d I n c l u d e l o a n s f r o m c a n d i d a t e ' s p e r s o n a l

TOTAL ( PART I ) $ X 1 0 0 - D- 0 TOTAL CASH REPAYMENTS ( PART I t )

PART I I - MONETARY LOAN REPAYMENTS MADE_THI S REPORTI NG PERI OD( L o a n s f o r g i v e n mu s t b e r e p o r t e d o n Sc h e d u l e E - - I n - k i n d C o n t r i b u t i o n s . )

F r o m Sc h e d u l e E - - TOTAL LOANS FORGI VEN $TOTAL OUTSTANDI NG LOANS END OF REPORT PERI OD $

Pa g e-o f __j( f o r S c h e d u l e F )

$ 80o, a - 6

SCHEDULEF LOANS

( R e v 0 8 / 9 6 ) RECEI VED& REPA I DCHECK T HI S BOX I FAMENDI NG FORM

DATE P AI D( MM/ DD/ YR) NAME AND ADDRESS OF LENDER( 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 ) RELATI ONSHI PTO CANDI DATE'I f A p p l i c a b l e )

AMOUNTREPAI D

' I 3 I TomI Y ) 0 ' c ' kao y I - I - i 1~. I aI V4 A",So-.P

I 4

$

DATERECEI VEDMM/ DD/ YRNAME AND ADDRESS OF LENDER( 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 ) RELATI ONSHI PTOCANDI DATE

I f A p p l i c a b l e * )AMOUNTOF LOAN

/vZq MC k e r l ~o Z C ) ~ / - ~ - t ' h I t ~ - v ~ c Q ~ ~ G a r eSMo u , ' 5 k a t . i L +&- ww 1 A5oI 5

CI c 3 , V 1 C Q C ,$~ . CD

SCHEDULE


25/25

FOR I NSTRUCTI ONS, SEE DA C ; ' K OF FORM

THI S FORM I S USED BY CANDI DATES' COMMI TTEES ONLY

COMMI TT EE NAME ( M u s t b e s am e a s o n S t a t e me n t o f O r g a n i z a t i o n )Mc,e, k

PART l l - I T EMI Z ED BREAKDOWN OF UNREI MBURSED EXPENSES P AI D BY CONSULT ANTTOOTHERS I N PERFORMI NG SERVI CESOF CONTRACT ( T h e s e e x p e n s e s s h ou l d NOT b ePART I - NAME AND ADDRESS OF CONSULTANT

r e p o r t e d o n Sc h e d u l e B , a s t h e y a r e d i r e c t p a y me n t f r o m t h e c o n s u l t a n t . )

Name o f Co n s u l t a n t_ j

. An r \

~42 1 ( 1 c ~ _

Mamng Ad d r e s s

C i t y

6( a&bY' ookTOTAL ANT I CI PATEDCOMPENSAT I ON FORCONTRACT PERI OD ( MM/ DD/ YR)

PERFORMANCE

Fr o mT o

s ? r ~ 2 i v r , ~At ' w 31 .

C Y ) Y ~-~-

EST I MATES OF PERFORMANCE

S t a t e

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I v S

r g e , ~~ r Y\

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$ GC~.'1I J G t ~ Q

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s l y - 75 - 0 , ( ) o

TD p ~d l v ~ S~,

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Ca l m A C + L : i c . ,

C~c~r ~mi } ~ e~

b r 1 mc442vS 0~ 0 r ~ ~CVY~ I ZC. . ~ l i o h~2cL~X t f V\ Q I l ' - A ' ~ r 2 l ~ cW~ u r e a - i . c x _ .C - l O I Z i Q N ~ ~ 1 J 1 l ~ G ~

~O~ I

P a g e _ _

- o f - - - ( f o r Sc h e d u l e G)

G BREAKDOWNOF MONETARY( Re v 0 2 / 9 6 ) EXPENDI TURESBY CONSULT ANTCHECKTHI S BOX I FAMENDI NG FORM

DATEEXPENDEDMM/ DD/ YR NAME AND ADDRESS TO WHOMEXPENDI TUREDi s b u r s e me n WAS MADE PURPOSE AMOUNTEXPENDED

S

SUB- TOTAL

TOTAL ( I f l a s t p a g e o f t h i s s c h e du l e ) $

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