~ 001

05%28%2015 (11 :07 FAX

5152768329 0210712006 16 :27 9248 P .003,1004
From " TIMMONS KROLL JACOBSE141

Revised 07/04
4~UL
Form DR-OTC
S AWD CAMPAIGN DISCLOSURE BOARD
610 EAST 12', SUITE 1A ONE-TIME CONTRIBUTION IN
EXCESS OF $760 BY A
DES MOINES, IA 60319 PERMANENT ORGANIZATION
Fax: (516)281-3701
www.towe .gov/ethics For office ust only,
indexed
bONITRIBUTION IN Excess OF $750 Audited
BY A PERMANENT ORGANIZATION Chocked
computer
Iowa Code section 68A402(9) regwres a perrrtenent organization that conVibutes In excess Of
X750 to register and floe reports as 1:i PAC. This form is Intended to serve those purposes. Itip
farm mUf4 be filed with the 823rtf olC1orb*ti~lg~the tenth day o_[the dalg the check was Issued .
ORGANIZATION MAKING CONTIUBUTION : 1

Mime
66,00 t_0 J~TW.V

Emall Address (Cptlonal) Area Code & Telephone No .

CONTACT PERSON FOR THE ORGANIZATION : _

Narne .9
I Mailing Address: City, late, Zip

Emall Addreas (Optional) Area Code & Telephone Number

CANDIDATE OR COMMITTEE RECEIVING THE CONTRIBUTION :

.

Name of Candl ate or Committee

r
2 :~-o+e $ ~~ 00
Malting Address City . State, zip Cede,
Date of Contribution Amount
/o L.K
Ema% Address (It available) Aces Code d Telephone Number
DOW of Election County (If ppl1Cabic)

~If contribution to candidate, disclose eotime of orlgk"I funds used to make

such contribution attach additional paw k neoessaty) . if In-Kind ContdbuVon, Oascrlbe

Criteria to me this form:

One campaign contribution In excess of 3760 was made to a state or local cxididale, party . political committee (PAC) for either a
candidate or a ballot Issue, or any other organization that advocates the election ordefeat of a candidate or ballot issue .
2. Must be e permanent organbation not established for election purposes .
3. No person gave money to tint organization for the purpose of the organization then using the money to make the contribution .
a. If the contribution was made to a candidate, no funds from a corporation or other prohibited contributor under Iowa Code section
GSA-503 were used to make the contribution (this does not apply to a contribution m2de to a ballot Issue committee) .
5. Only one contribution to any ~tempsign oommfe except for a ballot Issue committee was made In a calendar year. No more than one
contribution may be .made to any one ballot Issue committee during a ballot issue election. if more than one contribution and the total
amount of the contributions exceed $750 . the organization must moister with the Board as a political committee (PAC) within 10 days at
crossina the $760 threshold_

Statement of Affirmation :
I, mat tv. NQfr i 5
affirm that the conMbutlon reported above Is accurate . I further 3ftirm that the information conoemtng the organization is
correct and true to the best of my knowledp, : . 1 understand that by tiling this forth, I am subject to the laws found In Iowa Code chapter 68A and
admInIAratlve rules found in chapter 351 . I also understand that the failure to timely ale this form leads to the Imposition of civil ponafoes and the
intentional failure to file the form may lead to additional civil and criminal sendlons.

Signature

' Contribution - Includes goods or services that are provided for free or otherwise k>" than fair market value_