IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD

Form

SC4*
VERIFIED STATEMENT REGISTRATION (Out-of-State Committees) (Rev . 07103)

VERIFIEb STATEMENT REGISTRATION
(Out-of-State Committee)
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE . SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM . THIS FORM MUST BE FILED FOR EACH CONTRIBUTION IN EXCESS OF $50 COMMITTEE NAME

510 EAST 12th , SUITE 1A DES MOINES, IA 50319 www .iowa.g ov/ethics

For office use only Comm . # Indexed Audited Checked Computer

Official Name of Out-of-State Committee (Do not abbreviate committee name. Written explanation must be provided for Acronym).

Quad City Federation of Labor, PAC #8020 Mailing Address 311- -21st St . 12

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE IS REGISTERED OR OPERATES

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE (Use separate page if needed to list more than one entity)

City, State, Zip Code R27nR

State Board of Mailing Address P .O . Box 4187
T11inniG

Name of Jurisdiction

R1

er't i on_

Springfield, ---I 1

Telephone -( 2 3 7) 782-41A l

Ouad City Federation of Labor,AFL-C I 0 Mailing Address 311 2-21st St .
Rock

Name

Island, 11, 61201

City, State, Zip Code

PURPOSE OF COMMITTEE

Support candidates endorsed by the AFL-CIO

IOWA RESIDENT AGENT Typed Name of Iowa Resident

IOWA COMMITTEE RECEIVING CONTRIBUTION

Metiaa P
City, State, Zip Code

2740-160th Ave .

Mailing Address Telephone C-,15a) 246-2061 5

s n

Brian Wood for At-large 405 W . LeClaire Rd
Date Mailing Address If In Kind Contribution, Describe

Name of Committee

Eldridge, Ia 5274
Committee . ID #

Calamus, Ia 52729

10-21-05

Amount

$500 .00
VERIFIED STATEMENT OF COMMITTEE :

#2322

Check #

I i , attest that the contribution reported above is accurate and that the information about this out-of-state a M 1 i n .n committee is correct and accurate to the best of my knowledge. I also attest that the reports filed in the named jurisdiction comply with requirements that are substantially similar to Iowa Code section 68A .6, including the disclosure of all contributions received and all expenditures made. I further attest that the contribution reported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code section 68A .15, unless the Iowa recipient committee is a ballot issue committee. 1 understand that potential civil and criminal penalties may apply unless a copy of this forr9,has been filed with the Iowa Ethics and Campaign Disclosure Board within 15 days of the date of the contribution .

Treasrnrer
(Title)

1n-21-ng (Date)

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 122 SUITE 1A DES MOINES, IA 50319 www .iowa.gov/ethics

Form

VERIFIED STATEMENT REGISTRATION (Out-of-State Committee)
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE. SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM . THIS FORM MUST BE FILED FOR EACH CONTRIBUT ION IN EXCESS OF $50 COMMITTEE NAME

VERIFIED STATEMENT REGISTRATION (Out-of-State Committees) (Rev . 07103)

For office use only Comm . # Indexed Audited Checked Computer

Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym) .

City, State, Zip Code

Ouad City Federation of Labor, PAC #8020 Mailing Address 311 12 -21st St . -

Area Code

Telephone No .

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE IS REGISTERED OR OPERATES Name of Jurisdiction T11inois State Roard of Rlertions City, State, Zip Code

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE (Use separate page if needed to list more than one entity)

P .O . Box 4187
Singfold, _62708.

Mailing Address

Ii

Telephone

Ouad City Federation of Labor AFL-C I 0 Address 311 ;-21st St .. Rock Island .
City, State, Zip Code

Name

( 23 782 _4_1A 1 ~)

I1 . 61201__ .

PURPOSE OF COMMITTEE

Support candidates endorsed by the AFL-CIO

IOWA RESIDENT AGENT Typed Name of Iowa Resident

IOWA COMMITTEE RECEIVING CONTRIBUTION Name

Mplisa
City, State, Zip Code

Petersen

2740-160th Ave . Ia 52729

Mailing Address Telephone

Brinson Kinzer for Mayor
Date

of Committee

304 E . Lotte St Blue Grass 10-21-05

Mailing Address

Ia 52726

Calamus,

If In-Kind Contribution, Describe Check # Committee . ID #

61 (_S~W 246-20

Amount

$ 500 .00
VERIFIED STATEMENT OF COMMITTEE :

12320

I Ja ck i e McC l i nt O ck attest that the contribution reported above is accurate and that the information about this out-of-state committee is correct and accurate to the best of my knowledge. I also attest that the reports filed in the named jurisdiction comply with requirements that are substantially similar to Iowa Code section 68A.6, including the disclosure of all contributions received and all expenditures made . I further attest that the contribution reported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code section 68A .15, unless the Iowa recipient committee is a ballot issue committee. I understand that potential civil and criminal penalties may apply unless a copy of this forras been filed with the Iowa Ethics and Campaign Disclosure Board within 15 days of the date of the contribution. C' (Person submi ing form)

Treasurer
(Title)

10-21-05
(Date)

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
514 EAST LOCUST, SUITE 104 DES MOINES, IA 50309-1912

Form

D STATEMENT REGISTRATION
(Out-of-State Committee)
S NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE. SEND ORIGINAL COPY TO THE BOARD AND WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE. REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .

VERIFIED STATEMENT REGISTRATION (Out-of-State Committees) (Rev. 1100)

Comm. # Audited Checked Indexed

For office use only

Computer

Official Name of Out-of-State Committee (Do not abbreviate committee name. Written explanation must be provided for Acronym.) Quad City Federation of Labor_, PAC t 8090 Mailing Address

311 12 -21st -St. -

Rock Isl a-nd,
TREASURER

City, State, Zip Code

I1 . 61201

Area Code

(_309)

Telephone No.

788-1303

OTHER OFFICERS (Attach second page if needed) Name of Treasurer Mailing Address Telephone 0788-1803 Name of Chairperson '7 1-t St City, Stake, Zip Code

Jackie McCll.ntock
City, State, Zip Code

3112-21st St

4

ailing Address Telephone

Rock Island, Il 61201
esident

Bnr-k

IOWA RESIDENT AGENT

Island, Il 631 03

vjwu

Ta fl 3

City, State, Zip Code

/ 5-~~ , Tyge/_ am Iowa Resident 1? Mailing Address C A lN 7-0 A .-7W

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE (Use separate page if needed to list more than one entity)

Quad City Federation of Labor , AFL-CIO
X11 Q_71 ~t

Name

Telephone

Rnn

ct

Mailing Address

r3a.nd r 13

City, State, Zip Code

63203

PURPOSE OF COMMITTEE:

Support candidates endorsed by the AFL-CIO
IOWA COMMITTEE RECEIVING CONTRIBUTION

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE IS REGISTERED OR OPERATES

Illinois State Board of Elections
P .O . Box 4187 City, State, Zip Code Springfield, Mailing Address

Name of Jurisdiction

Committee to ElecTmar m 3330 Tremont Ave
Date Amount

omberg Iz 52803

9-8-04 200 .00

I

If In Kind Contribution, Describe

Ti

62708

Telephone 4141

017 )7g2-

$

VERIFIED STATEMENT OF COMMITTEE: I 1 ;4f-kip Mr f.1 i n t o ck . swear that the contribution reported above is accurate . I further swear that the information about this out-ofslate committee is correct and accurate to the best of my knowledge. I attest that the reports filed In the named jurisdiction comply with requirements which are substantially similar to Iowa Code section 56.6, including the disclosure of all contributions received and alt expenditures made. I further attest that the contribution reported above was made from an account, which does not accept contributions from corporations or other prohibited contributors under Iowa Code section 56.15. I understand that Iowa committees are prohibited from accepting contributions from out-of-state committees unless a signed original of this form has been filed with the owa Ethics and Campaign Disclosure Board, or the out-of-state committee is registered andfiling full Dscosure reports in Iowa.

/~ (Only Signature of Treasurer or Chairperson) 8t h Subscribed and swom before me this
My notary commission expires

Treasurer

September ; day of

(Title)

September, 8,,,2,004
(Date) ,

,;20,,. 4 at Davenport, la 52803

J -q'd2

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
514 EAST LOCUST, SUITE 104 DES MOINES, IA 50309-1912

Form

VERIFIED STATEMENT REGISTRATION (Out-of-State Committees) (Rev . 1100)

IED STATEMENT REGISTRATION

(Out-of-State Committee)

For office use only Comm . # Audited Indexed

EES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE. SEND ORIGINAL COPY TO THE BOARD AND _ PY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE. "PCe~iSE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM . COMMITTEE NAME

Checked Computer

Quad City_ Federation of T,abor, PAC # Rn?n Mailing Address 3.11 1-2-21st St . Rock Island . Il . 61201
TREASURER City, State, Zip Code

Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym.) Area Code

(309)

Telephone No. 788-1 R0-4

OTHER OFFICERS (Attach second page if needed) Narste of Treasurer Mailing Address Telephone (302-Y88-1803 erz V 1 ., . Name of Chairperson -- Mailing Address T1_ 6129-1 Telephone (38-g1~ R2-13

Jackie MCClintock 3112-21st_ St

IOWA RESIDENT AGENT l City, State, Zip Code

City, State, Zip Code Rock I-s1-and L 11~612O1

City, Stale, Zip Code Rnr+lr TclaTA

Ty' d-Name of Iowa Resident

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE (Use separate page if needed to list more than one entity)

_ Mailing Address C~lN eot ~~ -

Quad City Federation of Labor, AFL-C
nq
e ~ 1 1 x_71 cf94 SfMailing Address

Name

Sa

~ ~

Telep

land_ I3 61291

City, State, Zip Code

PURPOSE OF COMMITTEE:

Support candidates endors ed by the AFL-CIO
IOWA COMMITTEE RECEIVING CONTRIBUTION

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE IS REGISTERED OR OPERATES

Illinois State Board of Elections Mailing Address P .O . Box 4187
City, State, Zip Code :,, D i af i el d ,

Name of Jurisdiction

Date

Committee to Ele'CfmJo oTan"ck Mailina Address 01 ~,~ GY . Dam' ST - . D4y E'r!CP Q i ,

m

T1

62708

Telephone 4141 _017 ) 78?_

Amount 200 .00

9-8-04

I

If In Kind Contribution, Describe

VERIFIED STATEMENT OF COMMITTEE: 1 Ta r ki P McCl intock . swear that the contribution reported above is accurate. 1 further swear that the information about this out-ofstate committee is coned and accurate to the best of my knowledge. l attest that the reports filed In the namedjurisdiction comply with requirements which are substantially similar to Iowa Code section 56.6, including the disclosure of all contributions received and all expenditures made. Ifurtherattest that the contribution reported above was made from an account, which does not accept contributions from corporations or otherprohibited contributors under Iowa Code section 56.15. 1 understand that Iowa committees areprohibited from accepting contributions from out-of-state committees unless a signed original of this form has been filed wiih theloiva Ethics and Campaign Disclosure Board, or the out-of-state committee is registered and filing full disclosure reports in Iowa. (Only Signature of Treasurer or Chairperson) Subscribed and swom before me this My notary commission expires

Treasurer eptember day of S

8 th

(Title)

September
(Date)

2004;, 

-

20

04 at

Davenport, Ia 52803

,

Check #2323, returned, VSR is VOID as of 11/15/2005

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD

VERIFIED STATEMENT REGISTRATION
(Out-of-State Committee)
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE . SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM . THIS FORM MUST BE FILED FOR EACH CONTRIBUTION IN EXCESS OF $50 COMMITTEE NAME

510 EAST 12th, SUITE 1A DES MOINES, IA 50319 www.iowa.gov/ethics

Form

VERIFIED STATEMENT REGISTRATION (Out-of-State Committees) (Rev . 07103)

For office use only Comm . # Indexed Audited Checked Computer

Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym) .

City, State, Zip Code

Quad City Federation of Labor, PAC #8020 Mailing Address 311'- -21st St . 2
Rack 121 and

Area Code

7414=4=14-4

Telephone No .

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE IS REGISTERED OR OPERATES

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE (Use separate page if needed to list more than one entity)

City, State, Zip Code ti9'7nP

P .O . Box 4187

T11 inr)i s

State Rnard of F1ectinns
Mailing Address Telephone ( 237)

Name of Jurisdiction

Ouad City Federation of Labor,AFL-C I Mailing Address 311 ;-21st St . Rock Island, Il . 61201
City, State, Zip Code

Name

Springfield,1 1.

7-82-ala, l

PURPOSE OF COMMITTEE

Support candidates endorsed by the AFL-CIO

IOWA RESIDENT AGENT Typed Name of Iowa Resident Mel i sa Petersen Mailing Address Telephone

IOWA COMMITTEE RECEIVING CONTRIBUTION Name of Committee

Jeff Grindle for At-Large
Date

City, State, Zip Code

2740-160th Ave .

309 Circle Dr 10-21-05

Mailing Address

Calamus, Ia 52729

If In-Kind Contribution, Describe Check #

Riverdale, Ia 52722
Committee . ID #

C5j5 .3) 246-2063

Amount

500 .00

12323

VERIFIED STATEMENT OF COMMITTEE :

I ,T a nk i P M C 1 i n . o , attest that the contribution reported above is accurate and that the information about this out-of-state committee is correct and accurate to the best of my knowledge . I also attest that the reports filed in the named jurisdiction comply with requirements that are substantially similar to Iowa Code section 68A .6 including the disclosure of all contributions received and all expenditures made. I further attest that the contribution reported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code section 68A .15, unless the Iowa recipient committee is a ballot issue committee. l understand that potential civil and criminal penalties may apply unless a copy of this forp-pas been filed with the Iowa Ethics and Campaign Disclosure Board within 15 days of the date of the contribution . C Treasurer 10-21-05

(Personsu6fufting

oim)

(Title)

(Date)

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD

VERIFIED STATEMENT REGISTRATION
(Out-of-State Committee)
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE . SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM . THIS FORM MUST BE FILED FOR EACH CONTRIBUTION IN EXCESS OF $50 COMMITTEE NAME

?G~ c~,

510 EAST 12", SUITE 1A DES MOINES, IA 50319 www .iowa.gov/ethics

Form

VERIFIED STATEMENT REGISTRATION (Out-of-State Committees) (Rev . 07/03)

For office use only Comm . # Indexed Audited Checked Computer

Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym) .

City, State, Zip Code

Quad City Federation of Labor, PAC #8020 Mailing Address 311 12-21st St . -

Area Code

Telephone No .

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE IS REGISTERED OR OPERATES

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE (Use separate page if needed to list more than one entity) ouad

City, State, Zip Code A97nR

P .O . Box 4187

T11innis State Rnarrl of R1 petions
Mailing Address

Name of Jurisdiction

Springfield, -- .--I 1

Telephone

311 ;-21st St ..
Rock

City Federation of Labor,AFL-C I
Address

Name

( 2-1-7-)-7782-41A1

Island, Il . 61201

City, State, Zip Code

PURPOSE OF COMMITTEE

Support candidates endorsed by the AFL-CIO

IOWA RESIDENT AGENT Typed Name of Iowa Resident

IOWA COMMITTEE RECEIVING CONTRIBUTION

Melisa P
City, State, Zip Code

2740-160th Ave . Ia 52729

Mailing Address Telephone (_562 246 -9063

rspn

Citizens for Tom Engelmann 4552 Main St Davenport,
Date Amount Mailing Address

Name of Committee

Ia 52806

Calamus,

If In-Kind Contribution, Describe Check # Committee . ID #

10-21-05 250 .00

$
VERIFIED STATEMENT OF COMMITTEE :

2324

J a c k i e MC C l i n t O ck , attest that the contribution reported above is accurate and that the information about this out-of-state 1 committee is correct and accurate to the best of my knowledge. I also attest that the reports filed in the named jurisdiction comply with requirements that are substantially similar to Iowa Code section 68A .6, including the disclosure of all contributions received and all expenditures made . 1 further attest that the contribution reported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code section 68A .15, unless the Iowa recipient committee is a ballot issue committee . l understand that potential civil and criminal penalties may apply unless a copy of thi5,(Km has been filed with the Iowa Ethics and Campaign Disclosure Board within 15 days of the date of the contribution . Treasurer
(Title) (Date)

10-21-05

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12i'', SUITE 1A DES MOINES, IA 50319 www .iowa.gov/ethics

Form

VERIFIED STATEMENT REGISTRATION
(Out-of-State Committee)
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE . SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM . THIS FORM MUST BE FILED FOR EACH CONTRIBUTION IN EXCESS OF 50 COMMITTEE NAME

VERIFIED STATEMENT REGISTRATION (Out-of-State Committees) (Rev . 07103)

For office use only Comm . # Indexed Audited Checked Computer

Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym) .

City, State, Zip Code

Ouad City Federation of Labor, PAC #8020 Mailing Address 311 1-2-21st St .

Area Code I qAQ 1

Telephone No . Ana , te n -,

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE IS REGISTERED OR OPERATES T1 1 i nni -, Name of Jurisdiction State Rnard of Mailing Address Fl r?r on s

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE (Use separate page if needed to list more than one entity)

City, State, Zip Code ti97nR

P .O . Box 4187

Springfield, -,I1

Telephone

Ouad City Federation of Labor,AFL-C I 0 Address 311 ;-21st St .. Rock Island, 11, 61201
City, State, Zip Code

Name

237

7R- 1 24 a,

PURPOSE OF COMMITTEE

Support candidates endorsed by the NFL-CIO

IOWA RESIDENT AGENT Typed Name of Iowa Resident MeliRa t GPn Mailing Address Telephone

IOWA COMMITTEE RECEIVING CONTRIBUTION Name of Committee

City, State, Zip Code

2740-160th Ave .

P .O . Box 432 828 River Dr
Date

.p Pat-

Will f

At-T,a rqp Mailing Address

Princeton, Ia 52768
If In-Kind Contribution, Describe Check # Committee . ID #

Calamus, Ia 52729

(56 3)

246-2063

10-21-05

Amount

$500 .00
VERIFIED STATEMENT OF COMMITTEE :

2321

, attest that the contribution reported above is accurate and that the information about this out-of-state I la-Ck-1-e Mr-irit4Ck committee is correct and accurate to the best of my knowledge . I also attest that the reports filed in the named jurisdiction comply with requirements that are substantially similar to Iowa Code section 68A.5, including the disclosure of all contributions received and all expenditures made . 1 further attest that the contribution reported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code section 68A .15, unless the Iowa recipient committee is a ballot issue committee. 1 understand that potential civil and criminal penalties may apply unless a copy of this forms been filed with the Iowa Ethics and Campaign Disclosure Board within 15 days of the date of the contribution . 14 ~i 10-21-05 ~e ci Treasurer (Person submitt ng formy (Title) (Date)

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