You are on page 1of 1

13196886222 ; 03125105 11 :28ApA ;JetFa2L4490 ;Pa9e 1 11

Sent bv : LIBERTY BANK

FOR INSTRUCTIONS, SEE BAC ' 6F -FORM


CHECK ONE: FORM STATEMENT
a This is an initial+ Statement of Organizi(ipn ' MRR 2 5 2005 I DR-1 OF
0 This is an amended' Statement of Oro6izai.don (REV . 07f2004) ORGANIZATION
For Off-Igo Use Only
'An initial Statement of OfgenIzafion must be fl6{d within 10 days of the commiNoo's accepting ~ontribufions, Comm . #
making ozponditures, or incaning indebtedness exseadiag $'7W-_AAOendm&OL&must .baki vithin 30 days of Indexed ,fin
a change . Penallios maybe imposed for fate-filed Statements of Organization. Audited
Computer

COMMITTEE NAME ~ b

" G~ oldberg For City Council


IMPORTANT: Indicate typo of committee you are reporting for: O
(1 )StatawideJLegIslaCvo1Judge Standing for Retention Candidate (2 )Statewide PAC (3)State Party (4 )County Central Committee
(3 )County Candidate (t3 )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 Issue
COMMITTEE TREASURERtmandatory for all committees) COMMITTEE CHAIR (mandatory except for a candidate's committee
NmeII
Ryan O'Leary
Mallin Address I 1
1924 Muscatine Avenue
city, state I J, Zip Code
I _Iowa City, IA 52240

Phone ( 31e ) 936.7296

e-Mail
cyan@594ryan_com
INDICATE PURPOSE OF COMMITTEE- Check One Bo
_ Comment or description:
All Candidates Enter:
Office Sought : Iowa City Council

N/A
Political Party (if applicable) Year Standing for Elecdon:
CountylLocal Candidates and Local BallotifFranchise Committees Enter:
Date of Election : Nov 2005
County : Johnson

Candidate_ name 8 Address or Parent Entity !PACs. if applicablel


:. 1 Af6liata, or Soonnor
Chuck Goldberg

Name of Financial InstitutionRype of Acoount


Liberty Bank/Checklng

City d y 887.1128
Phone (319 )
Coralville, IA 52241
chuck.goldI)org@,ihrco.com
e-mail

STATEMENT OfAFFIRMATION: By filing this document the committee affirms the Wowing :

1 . The committee and all persons connected with the committee understand that they are subJect to the laws In Iowa Code chapters 66A and 68B and the administrative
ruses In Chapter 351 of the IcwF Administrative Cede .
2. That Iowa Code section 68A.402 and rule 351-4.9 require the filing of disclosure repons and +nit the failure to Me those reports on or before the required due dates
st9bjecis the candidate or chairperson (in the case of committees other than a candidate's committee) to the automatic: asseasmart of a civil penalty and the possible
imposition of other criminal and civil senctlons.
3. That Iowa Code section 68AA05 and rules 351-4.36 through 4.43 require the placement of the words -paid for by and the name of the committee on all political
mabonaIr oxcopt for those !toms exempted by staluta or rule . A Committee filing this statement for purposes of using the shorter 'paid for by and who have notcrossed
the $750 shall notify the Board teat the $750 threshold will not be crossed.
4 . That Iowa Code section 69A-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 onty expend campaign funds as permitted by Iowa code sections 68A.301 through 8BA.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
dr%owtion (Dfj-3) has been Nec.

Dace Signed