FROM :E&PA FAX NO . :712 246 1071 Dec .

17 2005 04 :55PM P1

Notice of Dissolution FORM

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NOW 1QE t7P

Wderod
Aadied
ConVoler

CO1MITTEE RAW

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Olbcial Name of CarwMtee

clly, state. zp Code

Am-a 1,446m*
Code

WHEN TO FILE:
The Notice of Diasolution frrast be fled within their (301 days of compk6on ofall the ib§awkV:

1. AN debts, loans and obligations have been paid ortrarskrred ;

2. AN campaign funds have been soert;
3. All campaign property soldall ortransfened (candidates orft and
4. A final report disclosing trarssactions cl0
.af the committee.

For state candidates and stats PACs, a &eai bank statswrent rnust be tied withthe Notice of Dissolution or as soonas
possible ifthe bank abatement is rat available at the time the Notice of Dis~n is fled.

fnature of Candidate or m6txef (if candda es OMMIMm

~s L 21 rJoEi
Da1B Signed

FOR INSTRUCnoNS, SEE BACK of FORM

This t~ L not applicable to staftry pmrrdicar txmw&bw--.