7S et%-i& _<~

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

514 EAST LOCUST, SUITE 104 VERIFIED STATEMENT
REGISTRATION
DES MOINES, IA 50309-1912 (Out-of-State Committees)
www.iowa.gov/ethic s (Rev . 07103)

VERIFIED STATEMENT REGISTRATION For office _use only

(Out-of-State Committee) Comm . #
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE.
SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND Audited
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM . 7.1

THIS FORM MUST BE FILED FOR EACH _CONTRIBUTION IN EXCESS OF $50 Computer LL

COMMITTEE NAME
Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym).
United Food & Commercial Workers Active Ballot Club ID# 8038
Mailing Address
1775 K Street, NW
Code Code No.
Washington, DC CA0b~jyy5~g f1~1~ 223-31jI ephone

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
IS REGISTERED OR OPERATES (Use separate page if needed to list more than one entity)

Name of Jurisdiction m
Federal Election Co United Food & _Commercial V orlers International Unio n
Mailing Address Mailing Address
999 E Street, NW 1775 K Street, NW
WKM*t&,i~F&20006- Tele Zip Code
424-9530-_ Washington, DC 200061598

PURPOSE OF COMMITTEE

Support Labor movement and any public official or candidate that works on its behalf.

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Jerry Messer Committee to Elect Jim Hancock
Mailing Address Mailing Address
6307 Kelling 2163 West_ 30`s Street, Davenport IA 52804
--------------
City, State, Zip Code Telephone Date I If In-Kind Contribution, Describe
I Davenport, IA 52806 319 323-3655 _9/_30_/04
9/30/04
---- )_ ---------
Amount Check _#__T Committee . ID #
200 .00 z <'<<Q1

VERIFIED STATEMENT OF COMMITTEE :

I Anthony M . Perrone , attest that the contribution reported above is accurate and (hat the information about this out-of-state
committee is correct and accurate to the best of my knowledge . 1 also a tie.5l 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 form hgs been riled with the Iowa Eth ampaign Disclosure Board within 15 days ofthe date ofthe contribution .
Scretary- Treasurer 9/__
30/04
(Title) (Date)
 IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form
VERIFIED STATEMENT
514 EAST LOCUST, SUITE 104 REGISTRATION
DES MOINES, IA 50309-1912 (Out-of-State Committees)
www .iowa.gov/ethics (Rev . 07103)

VERIFIED STATEMENT REGISTRATION For office use onto

(Out-of-State Committee) Comm . 12 ,_ __-
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE .
SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND Audited
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM.
THIS FORM MUST BE FILED FOR EACH CONT RIBUTION IN EXCESS OF $50 Computer -_

COMMITTEE NAME
Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym) .
United Food & Commercial Workers Active Ballot Club ID# 8038
Mailing Address
1775 K Street, NW
Code Code phone No.
Washington, DC (lb~ 223-31Tlle

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
IS REGISTERED OR OPERATES (Use separate page if needed to list more than one entity)

unsdiction
Federal Election Commisson _United Food &__Commercial WM orkers International Union
Mailing Address Mailing Address
999 E Street, NW 1775 K Street, NW
Telephooe State Zip Code
%Mfttb1P, b& 20006- 1
424-9530_- Washington, DC 20006yI598 '

PURPOSE OF COMMITTEE

Support Labor movement and any public official or candidate that works on its behalf.

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Jerry Messer Rhomberg for Supervisor
- - ------- -------- -------- ---------- --
Mailing Address ill Mailing Address
16307 Kelling 3330 Tremont Ave nue, Davenp ort IA 5280 3
-- - -- ----------
City, If
State, zip code Telephone Date ^ in-Kind Contribution, Describe
Davenport, IA 52806 319 323-3655 Ill 9/30/04
__ ---- )_--------- _- __---- --
Amount Check t< T Committee . ID 1r
$ 200.00

VERIFIED STATEMENT OF COMMITTEE :

I Anthony M . Perrone _, 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 riled 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 16, unless the Iowa recipient com ittee is a ballot issue committee. /understand that potential civil and criminal penalties may apply unless a copy of
this form,,4as been riled with the Iowa Et ' an Campaign Disclosure Board within 15 days of the date of the contribution .
retary-Treasurer 9/_30/04
------ -
-__-___ --
Title) (Date)-