FOR INSTRUCTIONS, SEE BACK OF FORM

CHECK ONE: FORM STATEMENT

F1 This is an initial* Statement of Organization DR-11 OF

F~ This is an amended* Statement of Organization (REV . 07/2004) ORGANIZATION

For Office Use Only
An initial Statement of Organization must be riled wi~liin-~Q ts Comm . #
making expenditures, or incurring indebtedness excdgdino' a0: ..A" Indexed
a change . Penalties may be imposed for late-filed Statemer)ts of Organization. Audited
Computer

COMMITTEE NAME
T K Philips for Supervisor
IMPORTANT : Indicate type of committee you are-r.epp1fin&fw;,, .~
(1 )Statewide/Legislative/Judge Standing for Retention Candidate (2 )Statewide PAC (3 )State Party (4 )County Central Committee
( 5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Political Subdivision Candidate ( 8 )County PAC ( 9 )City PAC
(10 )School Board or Other Political Subdivision PAC ( 11 ) Local Ballot Iss ue
COMMITTEE TREASURER (mandatory for all committees) COMMITTEE CHAIR (mandatory except for a candidate's com mittee)
Name Name
Lena M Philips Jim Gorham
Mailing Address
PaOntiox d 305 608 W Washington
City, State ~ ~ Zip Code 1 City, State .L- .t- Zip Code 1
Riverside, IA 52327 Washington, IA 52353

Phone ( 319 ) 430- 8 5 38 Phone ( 319 ) 653-1 627

e-Mail e-Mail
INDICATE PURPOSE OF COMMITTEE - Check One Box C Advocate for/against candidate(s) --1 Advocate for/against ballot issue(s)
Comment or description :
All Candidates Enter :
Office Sought : Supervisor
District :
Democrat 2004
Political Party (if applicable) Year Standing for Election :
County/Local Candidates and Local Ballot/Franchise Committees Enter:
Date of Election : 11/02/2004
County : Washington

Bank Account Name 1 ~- Candidate name & Address or Parent Entity (PACs, if applicable),
Affiliate,or Sponsor
T K Philips for Supervisor Terry K Philips
Name of Financial Institution/type of Account Mailing Address
Washington State Bank PO Box 305
Mailing Address City .( State Zip
PO Box 311 Riverside, IA 52327
City 1 1 State 648-5028
Phone (319 )
Washington, IA 52353
e-Mail

STATEMENT OF AFFIRMATION : By filing this document the committee affirms the following :

1. The committee and all persons connected with the committee understand that they are subject to the laws in Iowa Code chapters 68A and 68B and the administrative
rules in Chapter 351 of the Iowa Administrative Code .
2. That Iowa Code section 68A.402 and rule 351-4.9 require the filing of disclosure reports and that the failure to file these reports on or before the required due dates
subjects the candidate or chairperson (in the case of committees other than a candidate's committee) to the automatic assessment of a civil penalty and the possible
imposition of other criminal and civil sanctions.
3. That Iowa Code section 68A.405 and rules 351-4.38 through 4.43 require the placement of the words "paid for by" and the name of the committee on all political
materials except for those items exempted by statute or rule . A committee filing this statement for purposes of using the shorter "paid for by' and who have not crossed
the $750 shall notify the Board that the $750 threshold will not be crossed.
4. That Iowa Code section 68A.503 and rules 351-4.44 through 4.52 prohibit the receipt of corporate contributions by all committees except for statewide and local ballot
issue PACs .
5. A candidate and a candidate's committee may only expend campaign funds as permitted by Iowa code sections 68A.301 through 68A.303 and rule 351-4.25.
6. That the committee will continue to file disclosure reports until all activity has ceased, committee funds spent, debts resolved, and a final report and a statement of
dissolution (DR-3) has been filed.

Signature of Treasurer Date Signed

Signature of Candidate, OR, for all other committees, Chairperson Date Signed
FORM DR-1 (Rev . 0712003)STATEMENT OF ORGANIZATIONFor Office Use Only Comm .
Indexed Audited Computer
INSTRUCTIONS, SEE BACK OF FORM
CHECK ONE:
This is an initial" Statement of Organization X
This is an amended" Statement of Organization

An initial Statement of Organizatnwr must be filed within 10 days of the committee's accepting con
expenditures, or incurringIndebtedness exceeding $750. Amendments must be filed w&iir 30 days of a
may be imposedforlate-flied Statements of Organization.

COMMITTEE NAME 1 1 T. K. Philips for Superviosr

IMPORTANT: Indicate type of committee you are reporting for. (1 )StatewidsfLegislative Candidate ( 2 )Statewide
PAC ( 3 )State Party ( 4 )County/Local Candidate ( 8 )County PAC ( 6 )Ballot Issuefranchiss Committee ( 7 )
County/City Central Committee COMMITTEE TREASURER (mandatory for all committees)
COMMITTEE CHAIR (mandatory except for a candidate's committee)
Name Lens M. Philips Mailing Address P. 0. Box 305
Riverside, Iowa 52327
Phone ( 319-430-8538
Chairperson Name Jim Gorham
Mailing Address 608 W. Washington,
Washington, Iowa 52353
Phone (319-653-1627
0-
Mail INDICATE PURPOSE OF COMMITTEE -
Check One Box X Advocate for/against candidete(s) Advocate for/against ballot issue(s) Comment or
description :All Candidates Enter. Office Sought: Washington County
Supervisor District: Political
Party (if applicable) Democrat Year Standing for Election: 2004
County/Local Candidates and Local Ballot/Franchise Committees Enter County:
Date of Election : Nov. 2, 2004
Bank Account Name T. K. Philips for Supervisor
Washington State Bank
P. 0. Box 311
Washington Iowa 52353 Candidate
name &Address or Parent Entity (PACs. if applicable). Terry K. Philips
P. 0. Box 305
Riverside, Iowa 52327
319-648-5028

STATEMENT OF AFFIRMATION: By filing this document the committee affimra the following: 1. The committee and all
persons connected with the committee understand that they are subject to the laws in Iowa Code chapters 68A and 688 and the
administrative rules In Chapter 351 of the Iowa Administrative Code. 2. That Iowa Code section 68A.402 and rule 351-4.9
require the filing of disclosure reports and that the failure to file these reports on or before the required due dates subjects the
candidate or chairperson On the case of committees other than a candidate's committee) to the automatic assessment of a civil
penalty and the possible imposition of other criminal and civil sanctions. 3. That Iowa Code section 68A.405 and rules 351-4.38
through 4.43 require the placement of the words 'paid for by" and the name of the committee on all political materials except for
those items exempted by statute or rule . 4. That Iowa Code section 68A.503 and rules 351-4.44 through 4 .52 prohibit the receipt
of corporate contributions by all committees except for statewide and teal ballot issue PACs. 5. A candidate and a candidate's
committee may only mcpend cam~funds a itted by Iowa code sections 68A.301 through 5. 6.
That thecommittee will continue until all activity hasceased, committunds spent 35
and a final report and a statem dissol ;3) h~ been tiled.

Signed

Signature of Candidate, OR, for aKK c~amdrem, aiperson Date

signed Statement of Organization ye l l J ~~ ~-'
Form DR-1
Revised 0712003
when do I flte7

An initial Statement of Organization must be filed within 10 days of the committee's accepting contributions, making