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' J9n 08 05 10 :21p

FOR INSTRUCTIONS, SEE BACK OF FORM Resct Form


DISCLOSURE SUMMARY PAGE
COMMITTEE NAME (Must be same as on Statement of Organization)

IMPORTANT : Indicate by ;C type of committee you are reporting for:


( 1 )Statewide/Legislative/Judge Standing for Retention Candidate (2 )State PAC (3 )State Party
( 4 )County Central Committee ( 5 )County Candidate (6 )City Candidate ( 7 )School Board or Other
Political Subdivision Candidate (S )County PAC (9 )City PAC ( ID )School Board or Other Political
Subdivision PAC ( I I ) Local Ballot Issue
CANDIDATE COMMITTEES ONLY :
Candidate Name . ,..r" Political Part), (if applicable)
A P/ Late reports are subject to
possible civil and criminal
Office sought District (if Senate or House) penalties.

SIGNATURE OF PERSON FILING REPORT TELEPHONE DATE SIGNED

I AM FILING A E T FOR (t) ELECTION l(2)NON-ELECTION YEAR .


(report date) 4ndicate by

Local Committees, enter Date of Election


[]CHECK IF AMENDMENT TO REPORT DATED
/ l - .~x c. .; --/

Check if this is final (termination) report and attach Notice of Dissolution Form DR-3 . County 8 Local Committees, enter County in
which Election is held
(You must continue to fife reports until a DR-3 is filed.)

STATEMENT OF CASH ON HAND


CASH ON HAND at the beginning of the reporting period . (Total of all funds held by the
committee. This amount MUST be the same as the cash on hand at the end
of the last reporting period or must be zero if this is first report filed) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
ADD TOTAL MONEY TAKEN IN THIS PERIOD
Schedule A Cash Contributions total (Attach Schedule A) (*also see in-kind below) . . . . . . . ., .
Schedule F : Loans Received total (Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Schedule H : Total Sales of Campaign Property (Attach Schedule 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Schedule H applies to Candidates' Committees Only)
SUB-TOTAL . . . . . $
SUBTRACT TOTAL MONEY SPENT THIS PERIOD
Schedule B : Expenditures total (Attach Schedule B) ("also see debts and loans below) . . .
Schedule F : Loan Repayments total (Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASH ON HAND at the end of this reporting period (if final report balance must
be zero) (Attach DR-3) . . . . . . . . . . . . _ . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S __

'AID BILLS (From Schedule D - Attach Schedule : a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -,=


*IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedaie E) . . . . . . . .---- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S -
- OUTST ING LOANS (From Schedule F - Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
CANDIDATE COMMITTEES ONLY:
r
CONSULTANT BREAKDOWN (Schedule G Attached?) YES F_:: NO
VALUE OF CAMPAIGN PROPERTY (From SchedUle H - Attach Schedute S
Jan 08 05 10 :20p 712 - 263-8943 p. 3

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MONETARY
BUTIONS -- VIONEY TAKEN IN I (Rc,,. 07M) 1 RFGElaTS
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GRECK i His BOX Iv
Co?"VINTME- MAME t ,,'Ajsf 40 sarva as od7 &mlain'-fit of agii, uzahial-,; ALIENDIINIG FORM

371A-i7E ,CANENDATES 0015 : IF AGONTROUDOWS RECEIVED FMM A =t 50 WMITBAL A(.,T'IC',,',! LIS-1 THE PAC l0lil,'IIFICATION
NUMBER AND !HE PAC CHECK NUMBER lNnfE0SSGNArEDCQLUMK A UST OF W NMOMS * MWWU,E FROM THE IMVA EnTCS AND CAMPAIGN
ISISUDSME 8MR0

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1.1101i)l feli3l'10ilShi -P. Q:Tltf,'f the relationship column. for SCir-,dulc A)
Jan 08 05 10 :21p 712-263-8943 p. 4

FOR INSTRUCTIONS, SEE BACK OF FORM Rc~a --FITTrr

I
SCHEDULE
B MONETARY
EXPENDITURES -- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev, 07103) EXPENDITURES
STATE PAC COMMITTEES : NOTE: FOR CONTROUIIONS MADE TO STATEWIDE OR LEGISLATIVE
CANDIDATES. LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE CHECK THIS SOX IF
PAC CHECK NUMBER FOR EACH EXPENDITURE A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORM
ETHICS & CAMPAIGN DISCLOSURE BOARD,

COMMITTEE NAME (Must be same as on Statement of Organization)


r.t _ 1

CANDIDATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNT


DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDED
EXPENDED (if applicable) (Disbursement) WAS MADE
(MMIDDIYR) AND PAC
CHECK
NUMBER
ID# t

1D# ,,

'IrI_ CK#
.
V

ID#

CK#
~_
ID#
f

CK#

ID#

CK#

ID#

C K#

ID#

CK#

SUB-TOTAL_ / S .,-,,
TOTAL (iflast page of this schedule) I $

THIS BOX APPLIES TO CANDIDATES' COMMITTEES ONLY :


Purchases of certain campaign property costing 5500 or more must also be inventoried on Schedule H. (Refer to Schedule H rtistructions .)
Expenditures to personstentities providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized on
Schedule G by the amount, purpose, and date of each type of expenditure made by the personfen6ty on behalf of the candidate's committee. (Refer to
Schedule G instructions and Iowa Code 611A.a02(3)(i).)
Page 1 of

(for Schedule B)