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Frow TIonNS KROLL JACOHSEN 5152768329 01/2112006 10 :12 #171 P.

001/001

Jan 21 06 11 :11a Warren Frozen Foods 5159678171 p .2

From :TMONS KROLL JACOBSEN 5152768329 01/21/2606 09 :31 #170 P.002/002

Revised 12105

IOWA ETHICS AND CAMPAICsN DISCLOSURE BOARD


Form DR OTC
610 BAST 1 SUITE: fA e, ONE-TIIf1E CORTMUT1OIIIN
DES MONES, IA 803'19 Excess of 0M
BY A
I= (5151291-3701 AIRlwwRNr ORGANIZATIGN
www tows.govtethlC9 Forotfloo useonly
indexed
ONE-TIME CONTRIBUTION IN EXCESS OF $750 Atadted -
BY A PERMANENT ORGANIZATION Meoloed
Computer
fovea Code WGUon t9dA.407(0) requires a pw"Wnent organimaton that 60Mfibuteg In ex0en of
$750 to mWster and Me repartb as a PAC,_ This form b intended bmw those Wposea . -The

OROANIZATION MAWNG CONTRIWT(ON:{

, .L1A, Q6FA ;W
r,_-e Nis, .~ C- .
Name I
~r~ .r`3atc ~5: ~~~aoa _ .Sorrrp~
Mddng Address T Ctbr. state, zipCede

~9 Address mend) Area Coda RTebpho ns No.


i
CONTACT PER&ON FOR TM ORGANRATION:

Name
Milling Address City . slate, Zia
, g,6?-rf2'r'-/
_ Addtew (aptlorW) _Area Code aTefepTtom nuneer

CANp1DATE OR COIIIIIIIIR'EE RECEIVING THE CONTRIBUTION:

Name ofCand1date or Committee

Mulling Address CRY, tars, Code


r
S- 09
Dels of t:erdr6ullon
rlm) s{Mrt:
Email Address (if awDable) -lea Code BTetephone Number
Doe of Election
If eoMeidW on to crtdtdab, dgdaaa seeehe ofbalReeds used to make
Such oonlribuMae (attach addionsl pages 9 neoe eeorA If IrridndConliftlion, DOW*
Criteria to use this form :

1. Onecampalon cordr1bason In excess of 5750 was made to a stab or local candldeta, par% ponfeat committee (PAC) for afther a
candid ate ore ballot issue, crony oiharot9anfsatlon that advocates theelection or defeat of a candidate or ballot isauo.
2. Must be a pwmened organization not estabtieW for election purposes.
S, No person gave Moneyto theorganisation forcite purpose at thewpanRmtion then using the money to make the cor*tbugon.
4. If the contr4bullen was made to a candidate, no fundsfrom a corporation or aner prohiblled conMqutor tstdrlowa Cede section
.543 were used to mdta the contilbuflon (this does not apply to a contdbtbon made to a ballot Issue ccmmtttee~
6&A
5. Only one contribution to any campaign committee except tar a ballot issue comrudtaswasmade In a calendar year. No mart: than one
conhlbugon may be made to any one ballot issuecommittee dulng S hollet law* Shadow. If more than one cartMbution andthetotal
amount of the wntilbudoneexceed $750, the organization must raoktarwith ft Board as apofal oommidee (PAC) Within 10 days of
crosstna the S7ti01hroehotd .

Statement of AMrmaBon :

f.) r FAlrm that the cantribudon reported ,bays is accurate. I further atrirm that the Infarmadon concerning the arold don is
true to the bW ofmY kfi . t und6reterd that bY ferry 06 brat, lam subject to the Iowa found In Iowa Code chapter 55A and
- lWas found in d-ler 1 also understand that thealreoepesormeasoempeenion
fi4 t Bml R fill f ld t th It of avd p-Was end the
failure to toe1hhtaotymsy Io addltlof civil end pimknW sanctions.

"Contrlbuiion'4ndudes goods or services that are provided for hasor otherwtap law than fair madeat value,

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