FORINSTRUCT'ONS,

SEEBACKOFFORM
DISCLOSURE
SUMMARYPAGE s 't, [r!{ir_]s
ectiveJanuary 1, 2010, all statementsand rcportsfiledby new committeeB.
stateoffice mustbe filed electonically and effectiveJanuary 1, 2012, all t' /{ i rI .1:
Al{fi_
and reportsfiled by all cnrmmifteesfor stafe office mustbe frled

May 1, 2010, all statementsand reportsfor SfafePACsand Sfale a[,'af'f'Y

t2 nf{B:&9
Paftiesmustbe frledelectronically.

COMMfTTEE l,lAME (Musl b e same as on Statement of Oryanization)

Vote Yes Clive Library
;"f;T, I o,,".o,,*,
(Rev.1212009)
Standingfor RetentionCandidate ( 2 )State PAC( 3 )StateParty
( 1 )Statewide/Legislative/Judge | REPoRT
(4)CountyCentral Committee(5)GountyCandidate (6)CityCandldate(7)SchoolBoardorOtherPolitical
Subdivision PAC (
Candidate( I )CountyPAC ( I )CityPAC ( 10 )SchoolBoardor OlherPolitcalSubdivision
1I ) LocalBallotlssue

District(if Senateor House)

Late reportsare subjectto posslblecivll and crlminalpenaltles.Pursuantto lowa Codesections688.32A(7)and 68A.401(3),the candidale,for a
candidate'scommittee,and ihe chairperson,for any other type of commlttee,ls the Indiudualresponsiblefor ffllngtimelyand accuratereports.

515-242-2463 4tF'
TELEPHONE ,DATE SIGNED

pgs11164Final
1611n REPORTFOR(1) ELECTTON
(2)NON-ELECTTON
YEAR.
(reportdate) Indicateby#A
ECHECT IFAMENDMENTTO REPORT DATED LocalGommittees.enter Dale of Elec{ion

El Checkif this is final (termination)

reportand attachNoticeof DissolutionFormDR-3. Gounty& LocalCommittees,
enterCoungin
(Youmustcontinueto file reportsuntila DR-3is filed.) whichElectionis held
Polk

OF CASHON HAND
STATEMENT
CASHON H,ANDat the beginningof the repodingperiod. (Totalof all tundsheldby the
committee.This amountMUSTbe the sameas the cashon handat the end
of the lastreporting $
59.34
periodor mustbe zeroif thisis firstreportfiled.)...........................................
ADD TOTALMONEYTAKENIN THISPERIOD
Schedule total(Attrach
A CashContributions A) (*alsosee in-kindbelow)..................
Schedule 7.4r
Schedule total(AttachScheduleF)...................
F: LoansReceived
Schedule Property(AttachScheduleH)................
H: TotalSalesof Campaign
(ScheduleH apollesto Gandldates'CommittEesOnlvl
suB-ToTAL................
$ 66.75
SUBTRACT TOTALMONEYSPENTTHISPERIOD
total(AttachScheduleB) (*also seedebtsandloansbelow)............
ScheduleB: Expenditures 66.75
total(AttachSchedule
ScheduleF: LoanRepayments F)....................
period(iffinalreportbalancemustbe zero)..........................
CASHON I-IANDat theendof thisreporting $
*UNPAIDBILLS(FromSchedule
D - AttachSchedule D)................... .........
$
-lN KINDCONTRIBUTIONS
(FromSchedule E -AftachSchedule E)................... ..............$
*OUTSTANDING LOANS(FromSchedule F - AttachSchedule F).................... .................
$
BREAKDOWN(ScheduleG Attached?)
CONSULTANT _YES ./ NO
CANDIDATEGOMMITTEES
ONLY:
VALUEOF CAMPAIGNPROPERry(FromScheduleH -Attach ScheduleH) $
STATECOMMITTEES:Submita reconciledcampaignaccountbankstatementin Januaryof eachyear.
For Instructlons, See Back of Form SCHEDULE
I
.. MONEYTAKEN IN
A I ruoruernnv
CONTRIBUTIONS (Rev.07/03)| RECEIPTS
personalfunds)
(lncludingcandidate's
BoxrF
ff cnecrrrms
MME (Musfbe sameas on Sfafem
COMMITTEE entof Organization) AMENDING
FORM
Vote Yes Clive Library

STATE CANDIDATES NOTE: lF A CONTRIBUTIONlS RECEIVEDFROMA STATE PAC (PoLlTlcAL AcTloN CoMMITTEE),LIST THE PAC IDENTIFICATIoN
NUMBERAND THE PAC CHECKNUMBERIN THE DESIGNATEDCOLUMN. A LIST OF ID NUMBERSIS AVAILABLEFROMTHE IOWA ETHICSAND CAMPAIGN
DISCLOSUREBOARD.

MORETHAN$750TOYOURCAMPAIGN
NOTE:ANYPERSON,OTHERTHANAN INDMDUALTHATCONTRIBUTES MAYFIAVEFILING
ANDSHOULDIMMEDIATELY
RESPONSIBILMES CONTACTTHEBOARD.

GAUTION:Seclion688.32A(6),prohibitsthe useof informationcopiedfrom reporlsandstatementsfor solicitingcontributions

orfor any
commercialpurposeby any personotherthanslatutorypoliticalcommittees.

Ronni Begleiter
1481NW l08th Steet
Clive,IA 50325

TOTAL (lf last page of thls schedule)

' Disclosurelawrequirescandidatecommittees to disclosethe relationship
of any relativemakinga contribution to the
@mmittee.Relationship muslbe sho{,nto the thirddegreeof consanguinity (bloodrelatives)and affinity(relativesby I I
maniage). lf sumame of contributoris the same as candidate,but there is no P"g" of
familial enter"notapplicable"
relationship, intherelationship
column. (forSchedule A)
 :,
FOR'NSIRUCTTONS,SEEBACK OF FORM llnesetForm
fl SCHEDULE
E--I I
-- MONEYSPENTFROMCOMMITTEEACCOUNT
EXPENDITURES
B I uoruErRnv
(Rev.07l03) | EXPENDITURES
STATE PAC COMMITTEES: NOTE: FORCONTRIBUTIONSMADETO STATEWDEoR LEGISIATIVE
CANDIDATES,LISTTHE CANDIDATEIDENTIFICATION
NUMBERIN THE DESIGNATED
COLUMNANDTHE BoxrF
I cnecrrHrs
PACCHECKNUMBERFOR EACHEXPENDITURE.A LIST OF ID NUMBERSIS AVAILABLEFROMTHE IOWA AMENDINGFORM
ETHICS& CAMPAIGNDISCLOSURE BOARD.

COMMITTEE NAME(Musfbe sameas on Statement

of Organization)
Vote YesClive Library

D(PENDITURE (DESCR|BETMNSACTION)
(Disbu rsement) WAS MADE

Friendsof CliveLibrary Charitable donation to close out

1900NW 114thStreet Committee account.
Clive,IA50325
BankersTrust Co. bank analysis service fee
666 Grand Avenue
DesMoines,IA 50309

THIS BOX APPLIES TO CANDIDATES' COMMITTEES ONLY:

Purchasesof certalncampaignpropertycostlng$500 or more must also be Inventorledon ScheduleH. (Referto ScheduleH Instructions.)

Exp€ndituresto persons/entitiesproMdlngconsultlng,adverlislng,fund-ralslng,polling,managing,organlzlngseMces must also be detall ltemlzedon

ScheduleG by the amount,purpose,and date of each type of expendituremade by the person/enry on behalfof the candldate'scommittee.(Referto
ScheduleG instruclionsand lowa Code
I I
P"g" of

(for ScheduleB)