You are on page 1of 3

FORM

I
FOR INSTRUCTIONS, SEE BACK OF FORM
DISCLOSURE SUMMARY PAGE DR-2 DISCLOSURE
(Rev. 12/2005) REPORT
COMMITTEE NAME (Mustbe same as on Statement of Organization)
For Office Use Only
Comm . #
Logged in _
Scanned
Computer ,
di Audited
CAN
C ate Na Political Party (d applicable) File with :
u 1 Iowa Ethics and Campaign
Disclosure Board
Office Sought 510 E.12', Ste. 1A
M ' .I Des Moines, Iowa 50319
ii1"1K,la' Fax 515-281-3701
Late reports a4sljbiec to possible civil and criminal penalties . Pursuant to Iowa Code section 68B.32A(7)
the candidate, for a candidate's committee, and the chairperson, for any othertype of committee, is the
indivio"l responsible #filing timely and accurate reports.

V
TUBE OF Per& FILING REPORT TELEPHONE DATE SK94ED

I AM FILING A REPORT FOR (1) ELECTION /(2)NONaECT10N YEAR.


(report date) Indicate by # n
QCHECK IFMABOMENTTao REPORT DATED Local Committees, enter Date of Election

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

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_) ............................... .... .... .. ........$ 47 to .. ng
ADD TOTALMONEY 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 Properly (Attach Schedule H) .......... ._ ....__.. ...................... .... .....
(Schedule H aoolfes to Candidates' Committees Only)
SUB-TOTAL.._............._._ .$ W710. _"
SUBTRACT TOTAL MONEYSPENTTHIS PERIOD 15-L ICU

Schedule B: Expenditures total (Attach Schedule B) ("also see debts and loans below) . .................
Schedule F- Loan Repayments total (Attach SheF)_...._ ............._ ......... ..... .... .............. .___...__........
CASH ON HAND at the end of this reporting period (iffinal report balance must
be zero) (Attach DR-3)........._ . ...__............._.................._. ....__.. . ...................__............ ...._ ..........._ ............_ .$

SAID BILLS(From Schedule D - Attach Schedule D) ..............._ ....__............................... ._..___.._........... .___ ......$
'IN KIM CONTROtFIONIS (From Stele E - Attach Scied le E) ................._ ..._ ......_.. ..__ ..........._....___ ..........._._ .$
"OtnWANDBlG LOANS (From Schedule F -Attach Schedule F) .._ .........._ ...__...__........ . ..._ ._.._................__..._ .......$
CONSULTANT BREAKDOVM(Schedule G Attachedr?)
CANDIDATE co1ArTrE ONLY-
VALUE OF CAMPAIGN PROPERTY(From Schedule H - Attach Schedule H)
STATE COMMITTEES- Submit a reconciled campaign accouhtbank sw&rnerrit "wry of each year_
For Instructions, See Back of Form Reset Form SCHEDULE

CONTRIBUTIONS -- MONEY TAKEN IN


A I MONETARY
(Rev. 07/03) RECEIPTS
(Including candidate's personal funds)
Q CHECK THIS BOX IF
COMMITTEE NAME (Must be same as on Statementof Organization) AMENDING FORM

trim ,4 2^jd
~'
.f- ,.
~wf~_P ~l tr
STATE CANDIDATES WOTE : IF A CONTRIBUI19FN IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN TH ESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

NOTE : ANY PERSON, OTHER THAN AN INDIVIDUAL, THAT CONTRIBUTES MORE THAN $750 TO YOUR CAMPAIGN MAY HAVE FILING
RESPONSIBILITIES AND SHOULD IMMEDIATELY CONTACT THE BOARD .

CAUTION: Section 68B.32A(6), prohibits the use of information copied from reports and statements for soliciting contributions or for any
commercial purpose by any person other than statutory political committees.

DATE PA ID NUMB NAM AND ADDREWI"~* ~ITftfrr7- RELATIONSHIP AMOUNT q IF FOR


RECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-
(MMlDD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOME
I ~Pk 1,54 cat", da-
/ $
CK#~- BS CR15~-C VZi 4R
I ~at ?r
-.~ Cr;Z9 -De-
, CG~ CL v2/ G/ CK /O. U CI
ID#

rs3.i C R ~~ +~I 9~141--


-go . CK#

ID#

CK#

ID#

CK#

ID#

CK#

ID#

CK#

ID#

CK#

ID#

CK#
-.
ID#

CK#

ID#

CK#

SUB-TOTAL
$yoa
TOTAL (iflast page of this schedule) -- 1
$ cx~
Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee. Relationship must be shownto the third degree of consanguinity (blood relatives) and affinity (relatives by
marriage) . If surname of contributor is the same as candidate, but there is no Pageof -L
familial relationship, enter "not applicable" in the relationship column. (for Schedule A)
FOR INSTRUCTIONS, SEE BACK OF FORM 1 Reset roan SCHEDULE

EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT B


(Rev 071W)
MONETARY
EXPENDITURES
STATE PAC CONOOTTEES : NOTE.- FCONTRIBUTKM TO OR LEGISLATIVE
CANDIDATES, CANDIDATE DENTIFICATION NUMBER IN DESIGNATED COLUMN AND THE CHECK THIS BOX IF
PAC CHECK NUMBER FOR EACH D(PENDITURE. 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)

, ,c
r - . CANDIDATE NAtT AND Aff-1 RE;S TO WHOM PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDED
EXPENDED (if applicable) (OsWrsement) WAS MADE
(MM/DDYR) AND PAC
CHECK
NUMBER
-K M L' ~ a-A;6 ,¢ d s - .
AL M
//IA /" . er $
C3 9o
CKl c) 0
'--A,
-? .e~o-
&
c- L e~o-rr-a--a
1D#
~P /-&-U e,eAckfte- Czy 1-4, s
CK#
6
1D#

~ cK# /0 7

ID#
6,,, R e~ b U." CAN F -~,~-

F~ .fYt 11
1D# v

CK#

ID#

CK#

CK#

ID#

CK#

SUB-TOTAL $
TOTAL (ifIeStpa" of WS Sdiedule)
$ 1576

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 Sdhedde H inatrudions.)

Expenditures to personsiendties providing consutdng . advertising . fisrd-rairargl. polling . managing. cuganbing services mud also be deland Itemized on
Schedule G by the amount, purpose . and date of each type of expendbre made by the persoWenfity on behaff ofthe rw e's committee. (Refer to
Schedule G hrstrudions and Iowa Code 88A.402(3)(i).)

Page _.J- - of

(for Schedule B)