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8/7/2019 Tobias David__complete report__scanned

1/17

OR I NSTRUCTI ONS, SEE BACK OF FORMQNE:r T h i s i s a n i n i t i a l * St a t e me n t o f O r g a n i z a t i o n

* T h i s i s a n amend ed* St a t e me n t o f O r g a n i z a t i o n

COMMI TTEE NAME ( Re q u i r e d b y l a w )

MMI TTEE TREASURER T h i s a d d r e s s u s e d f o r a l l r e m i n d e r s a n dq u i r e d b y l a w) c o r r e s p o n d e n c e )

( 2 ) DONATED TO

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i n i t i a l St a t e me n t o f O r g a n i z a t i o n s h o u l d b e f i l l e d w i t h i n 1 0 d a y s o f t h e c o mmi t t e e ' s a c c e p t i n g c o n t r i b u t i o n s ,n g e x p e n d i t u r e s o r i n c u r r i n g i n d e b t e d n e s s e x c e e d i n g $ 5 0 0 . Ame n d m e n t s s h o u l d b e f i l e d w i t h i n 3 0 d a y s o f a. P e n a l t i e s may b e i mp o s e d f o r l a t e - f i l e d S t a t e me n t s o f O r g a n i z a t i o n .

i obi l A FOR&t JC. IL

I S POS I T I ON OF BALANCE OF FUNDS UPON DI SSOLUTI ONI n d i c a t e d i s p o s i t i o n o f f u n d s b y ma r k i n g a p p r o p r i a t e n u m b e r i n b o x :( 1 ) DONATED TO COUNTY CENTRAL COMMI TT EELOCAUSTATEf NAT' L P OL I T I C A L PARTY ( u n d e r l i n e o n e )( 3 ) DONATED TO CHARI TABLE ORGANI ZATI ON

( s p e c i f y ) I L ' s uL, T I PLC . C_ L . I ~ Q_CCI S ~~v~T~r ~( 4 ) CI TY/ COUNTY/ SCHOOUSTATE OF I OWA GENERAL FUND ( u n d e r l i n e o n e )( 5 ) PARTI SAN CONGRESSI ONAL DI S TR I C T FUND

, c 74 4 " ' 4Mt ' , t l Q.S i g n l K r e Candi d, i f PA e , Ce n t r a mmi t t e e o r L o c a l B a l l o t I s s u e , Ch a i r p e r s o n

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COMMI TTEE CHAI R ( L i s t a d d i t i o n a l o f f i c e r s o n s e p a r a t e p a g e )

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I MPORTANT: I n d i c a t e t y pe 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 ) S t a t e w i d e / L e g i s l a t i 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 un t y ] L oc a l Ca n d i d a t e ( 5 ) Co un t y PAC ( 6 ) B a l l o t I s s u e/ Fr a n c h iCo mmi t t e e ( 7 ) C o u n t y / C i t y C e n t r a l Co mmi t t e e ( 8 ) Su p po r t s l a t e o f c a n di d a t e s ( l i s t c a n di d at e s u n d e r p u r p o s e o f c o mmi t t e e

( S t a t e me n t o f i n t e n t r e q u i r e d b y l a w f o r a l l c o mmi t t e e s , e x c e p t s t a t e p a r t i e s a n d c e n tc o mmi t t e e s a n d c o mmi t t e e s u s i n g o n l y p e r s o n a l f u n d s . )( 6 ) PRORATED REFUND TO CONTRI BUTORS( 7 ) TRANSFER TO ANOTHER COMMI TT EE OF T HI S SAME CANDI DAT( CANDI DATES ONLY)( 8 ) RETURN TO PARENT ENTI TY GENERAL FUND ( PACS ONLY)( 9 ) OTHER ( P A Cs O NL Y ) , PLEASE BE SPECI F I C

OF AFF I RMAT I ON BY TREASURER AND CANDI DATE ; OR POL I T I CAL COMMI TTEES, BY CHAI RPERSONam a wa r e t h a t I am r e q u i r e d t o f i l e d i s c l o s u r e r e p o r t s i f t h e c o mmi t t e e r e c e i v e s c o n t r i b u t i o n s , m a k e s e x p e n d i t u r e s , o r i n c u r s i n d e b t e d n e s s i n e x c e s s o f. 0 0 i n a c a l e n d a r y e a r t o e x p r e s s l y a d v o c a t e f o r a n y c a n d i d a t e o r b a l l o t i s s u e . I u n d e r s t a n d t h a t a l t h o u g h t h e t r e a s u r e r n o r m a l l y p r e p a r e s a n d f i l e st h e c a n d i d a t e o r c h a i r p e r s o n ( PACs ) i s r e s p o n s i b l e u n d e r t h e l a w f o r a c c u r a t e a n d t i m e l y d i s c l o s u r e r e p o r t s a n d t h a t l a t e - f i l e d r e p o r t s a r e s u b j e c tp e n a l t i e s a n d p o s s i b l e o t h e r l e g a l a c t i o n . I u n d e r s t a n d t h a t b y f i l i n g t h i s f o r m , I am s u b j e c t t o t h e l a ws f o u n d i n I o wa Code c h a p t e r 5 6 , c h a p t e r 6 8 Ba d m i n i s t r a b v e F u l e s f o u p d i n c h a p t e r 3 5 1 . I a f f i r m t h a t a l l c o mmi t t e e o f f i c e r s h a v e b e e n i n f o r m e d o f t h e i r a p p o i n t me n t a n d o b l i g a t i o n s .

Name Name .

M a i l i n g Ad d r e s s M a i l i n g Ad d r e s sCok I 5 E06 LON A' J EC i t y , S t a t e Z i p Code C i t y , S t a t e Z i p CodeP ( ~ h 1 t _ f f x , i 1 f i c y , ~ ~ 1 S%gy p 3 r z ~ t t ~ - r = r S/ S3P h o n e ( ~~~) J ZJ ' ~~ ~ P h o n e ( - 1 / Z ) Z3 Ze - M a i l e - M a i lI NDI CATE PURPOSE OF COMMI TTEE- C h e c k One Bo x Ad v o c a t e f o r / a g a i n s t c a n d i d a t e ( s ) ~ / Ad v o c a t e f o r / a g a i n s t b a l l o t i s s u e ( s )Commen t o r d e s c r i p t i o n :A l l Ca n d i d a t e s E n t e r :

t ,( ~

D i s t r i c t &i e J t ' t ' SO f f i c e So u g h t : t aY f ~ C , f 1 C. i UP o l i t i c a l P a r t y ( i f a p p l i c a b l e ) Yea r S t a n d i n g f o r E l e c t i o n :Co u nt y / L o c a

~ l - _a n di d a t e s a n d L o c a l B a l l o t / F r a n c h i s e Co mmi t t e e s E n t e r : l %c, tCo u n t y : p - -i -T n y w. w f e l m I Da t e o f E l e c t i o n :

B a n k A c c o u n t Name Ca n d i d a t e n a me & Ad d r e s s o r Pa r e n t E n t i t y ( PACs , i f a p p l i c a b l e ) ,A f f i l i a t e , o r S p o n s o r~ A\ ) Io . X8 1 , 4 - s

NaA '' " I t ~o Fi n a nc i a l I n s t i t u t i o n / t y p e o f A c c o u n t 1 M a i l i n g Ad d r e s s qAy E - l y u cP" f 4 7 VA' l ~ L 66NK 4 2 - c ) HL wT t N&~ t JM a i l i n g Ad d r e s s . ~ 1 C i t y S t a t e I 1 Z i p J 1C i t y ~ . ~ . S t a t e I Z i p 1 1 Ph o n e ( - 7 1D D2 " L J q 9K

~ ' ) CJ L _ ) , 1 S ( , 3 e - M a i l


2/17

FOR I NSTRUCTI ONS, SEE BACK OF FORM

DI SCL OSURE SUMMARY PAGECOMMI TTEE NAME ( M u s t b e same a s o n St a t e me n t o f O r g a n i z a t l o r t )

r f ) g i . 4 S a2 Cn 0 t j CI LI MPORTANT : I n d i c a t e t y p e o f c o mm i t t e e y o u a r e r e p o r t i n g f o r( 1 ) S t a t e w i d e / L e g i s l a t i v e C a 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 ) 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 PAC ( 6 ) 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 mmi t t e e( 8 ) S u p p o r t S l a t e o f C a n d i d a t e s

SEP 46k- j r Z 6 * 0 1 1A

Ro u t i n e Pe n a 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 Ra n g e f r o m $ 2 0 t o $ 8 0 0SEE I NSTRUCTI ONS ON BACK AND COMPL ETE T HE FOL L OWI NG SENTENCE :

AM F I L I N G A FI n a n c i a j D s c OS / r( r e p o r t d a t e )

[ ] CHECK I F AMENDMENT TO REPORT DATEDChe 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 DR- 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 . )

ST AT EMENT OF CASH ON HAND

I n d i c a t e o n e

CASHONHAND 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 amount MUST b e t h esame 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

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 c e m u s tb e z e r o ) ( A t t a c h D R - 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 5 7

DR- 2 I DI SCLOSURE( R e v . 0 1 1 9 8 ) REPORTF o r O f f i c e U s e O n i vCommI n d e x e d -A u d i t e dC o mp u t e r

3 2 S- ` t Rq l . q - Z Y- 0 1SI GNATURE OF 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 ) TELEPHONE DATE SI GNED

REPORT FOR ANI A ( 1 ) ELECTI ON / ( 2 ) NON- ELECT I ON YEAR

L o c a l C o mmi t t e e s , e n t e r D a t e o f E l e c t i o nN0 q 6 1 L t 7IC o u n t y & L o c a l C o mmi 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 HI S PERI ODS c h e d u l e A Cash 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 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c h e d u l e F L o a n s R e c e i v e d t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,S c h e d u l e H T o t a l S a l e s o f Campa i gn P r o p e r t y ( A t t a c h S c h e d u l e H ) . . . . . . . . . . . . . . . . .

( S c h e d u l e H a p p l i e s t o C a n d i d a t e s ' Commi t t e e s O n e )SUB - TOTA L . . . . . $ 5 7 6 .SUBTRACT TOTAL MONEYSPENT THI S PERI OD

S c h e d u l e B : E x p e n d i t u r e s t o t a l ( A t t a c h S c h e d u l e B ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c h e d u l e F : L o a n Repa y men t s t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . 0 WL

5 7 0 ,

0 0

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UNPAI D B I L L S ( F r o m S c h e d u l e D - A t t a c h S c h e d u l e D ) . . . . . . . . . . . . . . . . . . . . . . . , . . , . . . . . . , . . . . $I N KI ND CONTRI BUTI ONS ( F r o m S c h e d u l e E - A t t a c h S c h e d u l e E ) . . . . . . . . . . . . . . . . . . . . , . . . . . . . . $OUTSTANDI NG LOANS ( F r o m S c h e d u l e F - A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , $NDI DATE COMMI TT EES ONL YNSUL T ANT BREAKDOWN ( S c h e d u l e G A t t a c h e d ? ) YES NO

OF CAMPAI GN PROPERTY ( F r o m S c h e d u l e H - A t t a c h S c h e d u l e H )


3/17

Fo r I n s t r u c t i o n s , See Ba c k o f F o r m. CONTRI 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 as o n St a t e me n t o f Or g an i z at i o n )

~~8 h 4 S~~ l ~ Y I Y l Gi l . _ .STATE CANDI DATES NOTE: I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I D EN T I F I C AT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETH I CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 6 8 B . 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 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 at 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 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 .

SUB- TOTAL $ ~ ' pTOTAL ( i f l a s t page o f t h i s

s c h e d u l e ) $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 an 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 ec o mmi t t e e . R e l a t i o n s h i p mu s t b e s how n 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 ) a n 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 r m s p a c k e t ) . I f s u r n ame 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 Pag e o ff a m i 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 u mn . ( f o r Sc h e d u l e A )

SCHEDULEA MONETARY

( Re v . 0 6 / 9 7 ) RECE I PTSQCHECK THI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT v I F FRECE I VED ( i 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 SNUMBER I NCOI D# MR , . , ~ WS~Ev UKSON Mu - r 4 e k' 2 6 22 4 t s e ' DCK# t Bi . ! ~ I S -b I P- ~ f F r HD# C l z r r x - , /CK# q' , t - ' L%q f ~ S~ - ~ k 3 D-I D # CH A r - L M, 4 7 ' ~ ' p kS- C- A CK# 2ZSf Wn l i n n bnA p s e 0 ~ ~ L I DCc S l S D 3I D # T I C~ n ; ~ . 1 - ~ ~ N I L L l r 4 , f ~ t SCK# Z ~ - i h % v k . T H 25 ~ ' S Tk , ` C- Sl J L II D # CNI ~. ~ S7 o P R C . - S v t 2 E u 5 C a t iCz -nNeP A2 t v ~CK# ~ o oC e ~~~sI D# SAMI KWl i 4( 7 - 1 0- 0 i 3 2- 1 ; ? ERR. l n l PLA4_CCK#

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4/17

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

( 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 St a t e me n t o f Or g a ni z at i on )

STATE CANDI DATES NOTE: I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I D E NT I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATEDCOLUMN. A L I S T OF I D NUMBERS I S AVA I LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCL OSURE BOARD .CAUTI ON : Se c t i o n 6 8 B . 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 m a t i o n c op 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 o n t r i b u t i o n s o rf o r an y c ommer 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 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 es .

SUB- TOTAL 0 0170

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1TOTAL r d l a s t page o f t h i ss c h ed u l e )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 mm i 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 emi 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 ) a n d a f f i n i t y ( r e l a t i v e s b ya r r i a g e ) ( Se e Page 2 o f f o r m s p a c k e t ) . I f s u r n ame o f c o n t r i b u t o r i s t h e s ame as c a n d i d a t e , b u t t h e r e i s n o Page 2 ^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 u mn . ( f o r Sc h ed u l e A)

SCHEDULEA MONETARY

( Re v . 0 6 / 9 7 ) RECE I PTSQ CHECK T HI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR REL AT I ONSHI P AMOUNT 1 I F FORECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECE I VED FUND( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SENUMBER I NCOM

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t CK# CC I K L _ gt - L Es 5 1 ~ 1/ 2 _ - &

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5/17

Fo r I n s t r u c t i o n 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 )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 )

T061as ~o r Co v n cdSTATE CANDI DATES NOTE: I F A CONTRI BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I DE NT I F I CA T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T 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 68 B . 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 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 emen 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 mmer c i a l p u r p os e by 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 es .

SUB- TOTALTOTAL ( i f l a s t page o f t h i s

s c h e d u l e )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 mm i 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. R e l a t i o n s h i p mu s t be s h o w n 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 ) a n d a f f i n i t y ( r e l a t i v e s b ya r r i a g e ) ( S e e Page 2 o f f o r m s p 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 ame a s c a n d i d a t e , b u t t h e r e i s n o Pa g e 3 o fr 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 . ( f o r Sc h e du l e A )

SCHEDULEA MONETARY

( Re v . 0 6 / 9 7 ) RECE I PTS( ] CHECK T HI S BOX I FAMENDI NG, FORM

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6/17

Fb r I n s t r u c t i o ns , See Back 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 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)

- CkS Pi D2

D i s c l o s u r e t a w r e q u i r e s c a n d i d a t e c o mm i 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 m a l t i n g a c o n t r i b u t i o n t o t h emi t t e e . R e l a t i o n s h i p mu s 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 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 ) a n d a f f i n i t y ( r e l a t i v e s b yi a g e ) ( S e e P a g e 2 o f f o r m s p 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 same a s c a n d i d a t e , b u t t h e r e i s n or 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 .

STATE CANDI DATES NOTE : I F A CONTR I BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I D EN T I F I C AT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T 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 68 B . 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 m a 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 men 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 o mmer c i a l p ur 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 l i t i c a l c o mmi t t e es .

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SCHEDULEA MONETARY

( Re v . 0 6 / 9 7 ) RECEI PTSQCHECK T HI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT ~ i I F FORECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECE I VED FUND-( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOMI D# V&7aP. ICAL WI LLI A t i 1 S $/ t a i2 0 0 o - / 0 46 . 2Z5TCK# ( ? j - 8&L~ , ~ 1

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7/17

FOR I NSTRUCT I ONS, SEEBACK OF FORM

DI SCLOSURE SUMMARYPAGE OCT 8 2 0 0 1COMMI TTEE NAME ( Mu s t b e s ame as o n St a t e me n t o f O r g a n i z a t i o n )To b i d s - ( o , f t , ;I MPORTANT . I n d i c a t e t y p e o f c o mmi t t e e y ou a r e r e p o r t i n g f o r.( 1 ) S t a t e wi d e l L eg i s l ad v e Ca n d i d a t e ( 2 ) S t a t e wi d e PAC ( 3 ) S t a t e P a r t y ( 4 ) Co u n t y / L o c al Ca nd i d a t e( 5 ) Co u n t y PAC ( 6 ) B a l l o t I s s u e / F r a n c t i i s e Co mmi t t e e ( 7 ) Co un t y / Ci t y Ce n t r a l Co mmi t t e e( 8 ) Su p p or t S l a t e o f Ca n d i d a t e s

SI GNATURE OF 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 ) TELEPHONERo u t i n e P e n a l t i e s Du e Fo r L a t e F i l e d Re po r t s R a n g e f r o m $ 2 0 t o $ 8 0 0

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( r e p o r t d a t e )[ ] CHECK I F AMENDMENT TOREPORT DATED

1 7 Ch 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 .( 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 . )

REPORT FORAN/ A ( 1 ) ELECT I ON / ( 2 ) NON- EL E CT I ON YEAR.I n d i c a t e o n e

STATEMENT OF CASH ON HANDCASH 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 mmi t t e e . T h i s amo 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

ADD TOTAL MONEYTAKEN I N T HI S PERI ODSc h ed u l e A : Ca 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 Sc h e d u l e A ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h ed 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 Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h ed u l e H : T o t a l Sa l e s o f Camp a i g n P r o p e r t y ( A t t a c h Sc h ed u l e H ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

_ ( Sc he d u l e H a p p l i e s t o Ca n d i d a t e s ' Commi t t e e s On l y )SUB- TOTAL . . . . .

SUBTRACT TOTAL MONEYSPENT T HI S PERI ODSc h ed u l e B : E x p e n d i t u r e s t o t a l ( A t t a c h Sc h e d u l e B ) . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . , . , . . . . . . . . . . . . . . , . . . . . , . . , .Sc h e d u l e F : L o a n Re p ay me n t s t o t a l ( A t t a c h Sc h e d u 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 al a nc e mus tb e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

UNPAI D BI L L S ( F r o m Sc h ed u l e D - A t t a c h Sc h e d u l e D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ; , ; - a 4. o /I N KI ND CONTRI BUTI ONS ( F r o m Sc he d u l e E - A t t a c h Sc h e d u l e E ) . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ y l b o

OUTSTANDI NG LOANS ( F r o m Sc h e d u l e F - A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . , . . . . . . . . . . . . . . $ .CANDI DATE COMMI TTEES ONLY :CONSULTANT BREAKDOWN ( Sc he d u l e G A t t a c h e d ? ) YES NOVALUE OF CAMPAI GN PROPERTY ( F r o m Sc h e d u l e H - A t t a c h Sc h e d u l e H)

DATE SI GNED

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 nMA t ? I ( g . 2 0 0 1C o u n t y & L o c a l Com i t t e e s , e n t e r C o u n t y i nwh i c h E l e c t i o n i s h e l d

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8/17

Fo r I n s t r u c t i o n 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 )COMMI TTEENAME ( 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)

Tobl n ~o r Co v n c l ISTATE CANDI DATES NOTE : I F A CONTRI BUT I ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ONCOMMI TTEE) , L I S T THE PAC I D EN T I F I C AT I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T 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 6 8 B . 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 m a t i o n c op i ed f r om r e p o r t s a n d s t a t emen 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 ny c ommer c i a l p u r p os e by a n 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 s t page o f t h i s

s c h e d u l e ) l $$ 205=

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 m mi 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 emi t t e e . R e l a t i o n s h i p mu s 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 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 ) a n d a f f i n i t y ( r e l a t i v e s b ya r r i a g e ) ( S e e P a g e 2 o f f o r m s p 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 me a s c a n d i d a t e , b u t t h e r e i s n o P a g e~-o f 7 1r 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 . ( f o r Sc h e d u l e A )

SCHEDULEA MONETARY( Re v . 0 6 / 9 7 ) RECE I P TSQCHECK T HI S BOX I F

AMENDI NG FORM

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9/17

Fo r I n s t r u c t i o ns , See Back 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 TTEE NAME ( Mu s t b e s ame 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)

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SUB- TOTAL

SCHEDULEA I MONETARY( Re v . 0 6 / 9 7 ) RECEI PTSQCHECK T HI S BOX I FAMENDI NG FORM

STATE CANDI 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 D E NT I F I C AT I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T 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 68 B . 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 m a t i o n c o p i ed f r o m r e p o r t s a n 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 rf o r a n y c o mme r c i a l 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 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 .

$ 310 - $ 51 5

TOTAL ( i f l a s t page o f t h i ss c h e d ul e )

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 emi t t e e . R e l a t i o n s h i p mu s 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 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 ) a n d a f f i n i t y ( r e l a t i v e s b y( S e e Pa ge 2 o f f o r m s p a c k e t ) . I f s u r n ame 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 P a g e~-o fr 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 )

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT 4 I F FRECE I 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 ) RA I SENUMBER I NCOMI D# T~ k G a n 9 v i 5 ~+ 2 S - 0 1 CK# I g o o Gr og A v x $ I 0 o 0C d TA 5 1 5 0 3I D# To , - Mass

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10/17

S BOX APPLI ES TO CANDI DATES' COMMI TTEES ONLY :c h a s e s o f c e r t a i n c a mp a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r mo r e mu s t a l s o b e i n v e n t o r i e d o n Sc h e d u l e H . ( R e f e r t o Sc h e d u l e H i n s t r u c t i o n s . )

i t u r e s t o p e r s o n s l e n t i f e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , o r g a n i z i n g s e r v i c e s mu s t a l s o b e d e t a i l i t e m i z e d o ne G b y t h e a mo u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e m a d e b y t h e p e r s o n / e n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o mmi t t e e . ( R e f e r t oe G i n s t r u c t i o n s a n d I o wa Co d e 5 6 . 6 ( 3 ) ( 1 ) . )

( f o r Sc h e d u l e B )

FOR I NSTRUCTI ONS, SEEBACKOF FORM SCHEDULEEXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT ( Re v . 0 9 / 9 7 ) EXPENDI TURESPAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLAT I VEDI DATES, UST THE CANDI DATE I DENTI F I CATI ON NUMBER I N THE DES I GNATED COLUMN ANDTHE CHECK THI S BOX I FCHECK NUMBER FOR EACH EXPENDI TURE . A UST OF I D NUMBERS I S AVA I L ABLE FROM THE I OWA AMENDI NG FORMI CS & CAMPA I GN DI SCL OSURE BOARD .

MMI TTEE NAME ( Mu s t b e s a m e a s o n St a t e me n t o f O r g a n i z a t i o n )T0 b l a s -~o r C v v n c l I

CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED( 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 MADEMM/ DD/ YR) AND PACCHECK

NUMBERI D# Un ; a n 6 t P r j n t i r n q C o m p a n y Down p 4 y o e . f a n 500 y a r d 5 i , r + 5

1 3 6 ) 9 NW. R a ~ i o I l + ( o ~ wd y $ ` 0 0 0CK# Or n c ~ d Ne b r a s k a 6 8 1 3 2I D# Th e D o i l y N o n p 3 r e i l Ne ws f a f e r Ad s - 1 0- Z ` I - 0 1

I 1 7 P e d r l S t z 7 1 .c K# C c j e c i I %S~ s , I A S I S O9I D# Vn i p , , ; 5 1 Fr A ; ' ( DI P f as y P aym4 f i ' n Ul o n f e c e i p t of

- 0 1 CK# I ) O q N. W . R a d ; , l H ; y k w r . y y , , 1 s i l r , t i X77 . 5 4C md l + ~ Ne 6 r a s l c 6 S 3 2I D#CK#D#CK#I D#CK#D#CK#I D#CK#

SUB- TOTAL $ 7 5 - 0 , 24TOTAL ( i f l a s t p a g e o f t h i s s c h e d u l e ) $ ( 75 0 . Z47


11/17

I NSTRUCTI ONS, SEE BACK OF FORMr. OMMf TTEENAME ( Mu s t b e s ame a s o n St a t eme n t o f O r g a n i z a t i o n )

TO L I * a s To r ( OUnCI 1NOTE : De b t s p r e v i o u s l y r e p o r t e d t h a t r e m a i n u n p a i d mu s t b e i n c l u d e d o n t h i sS c h e d u l e , a s w e l l a s a n y n e w o b l i g a t i o n s i n c u r r e d i n t h i s p e r i o d .DEBTS / OBL I GAT I ONS REMAI NI NG T HI S REPORTI NG PERI OD( DO NOT I NCLUDE LOANS - SHOWLOANS ON SCHEDULE F )

f i g u r e I s u n k n o w n , s h o w " e s t i m a t e d ' b e s i d e t h e f i g u r e .

SCHEDULED I NCURRED( R e v . 0 8 / 9 8 ) I NDEBTEDNESSCHECK THI S BOXI F AMENDI NGFORM

An i n c u r r e d d e b t " i s a d e b t f o rg o o d s o r s e r v i c e s o r d e r e d o rr e c e i v e d , b u t n o t p a i d f o r b y t h ee n d o f t h e r e p o r t i n g p e r i o d . ,r e g a r d l e s s o f w h e t h e r a n i n v o i c eh a s b e e n r e c e i v e d .

P a g e o f( f o r S c h e d u l e D )I DATE COMMI TTEES NOTE :I n d e b t e d n e s s a l s o I n c l u d e s e a c h p e r s o n l e n t i t y w i t h w h om t h e c a n d i d a t e ' s c o m m i t t e e h a s e n t e r e d i n t o a c o n t r a c t d u r i n g t h e r e p o r t i n g p e r i o d f o r f u t u r ep e r f o r m a n c e . E n t e r t h e name o f t h e c o n s u l t a n t wh o p r o v i d e s o r p r o c u r e s s e r v i c e s f o r i t e m s s u c h a s a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g ,n i z i n g s e r v i c e s . R e p o r t o n S c h e d u l e G t h e n a t u r e o f p e r f o r m a n c e a n d t h e e s t i m a t e d p e r f o r m a n c e r e a s o n a b l y e i p e c t e d o f t h e c o n s u l t a n t

DATEI NCURRED( MM/ DD/ YR) NAME AND ADDRESS OF PERSONTOWHOMDEBT OR OBLI GATI ON I S OWEDDESCRI PTI ON OF GOODSORSERVI CES PROVI DED ORPURCHASED

BALANCE OWED ATCLOSE OF` REPORTI NGPERI OD'

0 - ~ - 0 1Th e Do d Y NonPo r e d1 1 7 r e a r ( S t .C o v n C 1 1 5 I d ` I S~ TA 5 ) S0 3

" S e e n a r i l uf T Ca J , , A J7 d a y s

?0 _on

SUB- TOTAL $

TOTAL DEBTS OWED BY COMMI TTE E AT THE END OF THI S REPORTI NGPERI OD $ 7 0 , 0 1u

Cs(unot Cd


12/17

I NSTRUCTI ONS, SEEBACK OF FORMCOMMI TTEE NAME ( Mu s t b e s ame as o n St a t e me n t o f O r g a n i z a t i o n )

T o b i a s f o r ( o un c l ~

SCHEDULEE I N K I ND( Re v . 0 6 / 9 7 ) 1 CONTRI BUT I ONS

CHECK T HI S BOX I FAMENDI NG FORM

TOTAL Of l a s tp a g e o f t h i s

s c h e d u l e )

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 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 ma k i n g an i n k i n d c o n t r i b u t i o n t o t h e Page o fmi t t e e . R e l a t i o n s h i p mu s t b e s h o w n t o t h e t h i r d d e gr 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 ( f o r Sc h e d u l e E )a r r i a g e ) . ( Se e Pa ge 2 o f f o r ms p ac k et ) 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 ame a s c a n d i d a t e , b u t t h e r e I s n or 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 .

DATERECEI VEDMM/ DD/ YR) NAME AND ADDRESSOF CONTRI BUTORRELAT I ONSH I PTO CANDI DATE

' ( i f a p p l i c a b l e )DESCRI PT I ONOF I N K I NDCONTRI BUT I ON

EST I MATEDF AI R MARKETVALUEJ I F FORFUND- RA I SERCONTRI BUTI ON

, TrM F o u s t1 2 1 1 F a i r r m o v h + Av e( Oo n c i I B1A _ 1A 5 1 5 " 0 3

2 0, x q ' 6 c n n t rl a b o r o n P 6 i o f i n ,

1 6 0 , v o-

i I I I I i


13/17

FORI NSTRUCTI ONS, SEE BACK OF FORM

DI SCLOSURE SUMMARY PAGECOMMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g an i z at i o n)T A i a s ~ o r ( n un c ' ) lI MPORTANT : I n d i c a t e t y p e o f c o m m i t t e e y o u a r e r e p o r t i n g f o r .( 1 ) S t a t e w i d e l L e g i s l a d v e C a 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 ) C o u n t y i L o c a l C a n d i d a t e( 5 ) C o u n t y PAC ( 6 ) 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 a n t r a l C o mmi t t e e( 8 ) S u p p o r t S l a t e o f C a n d i d a t e s

3 2 S - ` } ~ f g ~ ~ ~ -SI GNATUREOF TREASURER ( o r p er s o n f i l i n g t h i s r e p o r t ) TELEPHONE DATE SI GNED

R o u t i n e P e n a l t i e s Du e F o r L a t e F i l e d R e p o r t s Range f r o m $ 2 0 t o $ 8 0 0GJLECT I ON YEAR.

SEE I NSTRUCTI ONS ON BACK ANDCOMPLETE THE FOL LOWI NG SENTENCE :I AMFI UNGA 5 + o mn n l l ~l I ~ ~ ~ u y

( r e p o r t d a t e )OCHECK I F AMENDMENT TOREPORT DATED

e c j i o - REPORT FORAN/ A ( 1 ) ELECT I ON/ ( 2 )I n d i c a t e o n e

n Che 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 an 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 must 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

CASH ONHAND 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 by t h e c o mmi t t e e. T h i s amoun t MUST be t h esame a s t h e c a s h o n h an d a t t h e en 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 mus t be 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 THI S PERI ODSc h e d ul e A : Cash C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e du l e A ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d ul 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 Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e du l e H : T o t a l Sa l e s o f Camp a i g n P r o p e r t y ( A t t a c h Sc h e du l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

_ Sc h e d u l e H ap pl i es t o Ca n d i d a t e s ' Commi t t e e s On l y lSUB- TOTAL . . . . . 5

SUBTRACT TOTAL MONEYSPENT THI S PERI ODSc h e d ul e B : E x p e n d i t u r e s t o t a l ( A t t a c h Sc h e du l e B ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d u l e F: L o a n Re p a yme n t s t o t a l ( A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

L o c a l C o mmi t t e e s , e n t e r D a t e o f E l e c t i o n

C o u n t y & L o c a l C o mmi t t e e s , e n t e r C o 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 en 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 c e must o obe z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

UNPAI D BI L L S ( F r o m Sc h e d ul e D - A t t a c h Sc h e d ul e D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $I N KI ND CONTRI BUTI ONS ( F r o m Sc h e d ul e E - A t t a c h Sc h e du l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $UTSTANDI NG LOANS ( F r o m Sc h e d u l e F - A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ANDI DATE COMMI TTEES ONLY :NSULTANT BREAKDOWN ( Sc h ed ul e G A t t a c h e d ? ) YES NOUE OF CAMPAI GN PROPERTY ( F r o mSc h ed ul e H - A t t a c h Sc h e du l e H )

FORMDR- 2{ Re v . 0 1 / 9 8 )

F o r O f f i c e Us e O n l yComma#

.f r i d e x e d ' -A u d i t e dCo mp u t e r ,

5 6 S

5 1 q . z b

DI SCLOSUREREPORT


14/17

o r I n s t r u c t i o n s , Se e Back o f Fo r mONTRI 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 )MI TTEE NAME ( Mu s t b e same a s o n St a t e me n t o f Or g a n i z a t i o n )

Tol i as ~o r Covnc i ICANDI DATES NOTE : I F A CONTR I BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACT I ON COMMI TTEE) , US T THE PAC I D E NT I F I C A T I ONAND THE PAC CHECK NUMBER I N THE DESI GNATEDCOLUMN A UST OF I D NUMBERS I S AVA I LABLE FROM THE I OWA ETHI CS AND CAMPAI GNSCLOSURE BOARD .

UTI ON : S e c t i o n 6 8 8 . 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 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 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 rr a n y c o mme r c i a l p u r p o s e b y a ny p er 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 s t p ag e o f t h i ss c h e d u l 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 emi t t e e . R e l a t i o n s h i p mu s 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 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 ) a n d a f f i n i t y ( r e l a t i v e s b ya g e ) ( S e e Pa ge 2 o f f o r m s p a c k e L ) . 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 ame a s c a n d i d a t e , b u t t h e r e i s n o P a g e o fr 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 . ( f o r Sc h e d u l e A)

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

CHECK T HI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR REL A T I ONSHI P AMOUNT J I F FORRECE I VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECE I V ED FUND-MM/ OD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOMEI D9 D c l o r e s De n f o nCK# 3 5 0 Z i o " Av

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