AUG-29-2005 Revised 07104

12 :32

SECURITY BANK

712 277 5558 Form DR-OTC

P . 01% 01

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12TH , SUITE 1A DES MOINES, IA 50319 Fax : (515)281-3701
www.iowa .gov/ethics Recet Form

ONE-TIME CONTRIBUTION IN EXCESS OF $750 BY A PERMANENT ORGANIZATION For office use only Indexed Audited Checked Computer

ONE-TIME CONTRIBUTION IN EXCESS OF $750 BY A PERMANENT ORGANIZATION
Iowa Code section 68A.A02(9) requires a permanent organization that contributes in excess of $750 to register and file reports as a PAC. This forth is intended to serve those purposes . Th_q form must be filed with the Board on or before the tenth day of the date the check was issued .
ORGANIZATION MAKING CONTRIBUTION :'
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Mailing Address

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"X Ci fi x . City, State . zip code ?/ti- -x -77 Area Code d Telephone No . P5S

Email Address (Optional) CONTACT PERSON FOR THE ORGANIZATION :

CANDIDATE OR COMMITTEE RECEIVING THE CONTRIBUTION : Name of Candidate or Committee 1 o1 Mailing Address

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200 5
C &, Z'0, City, Stale, Zip Code Irol a o0 Amount Wuo44 County (If Applicable) If In-Kind Contribution, Describe

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J C'" o o /S "40 " - oo ) e i'+q Email Address (if available)

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7 l z - 2 5ef - o o6 S Area Code & Telephone Number

If contribution to candidate, disclose source of original funds used to make such contribution (attach additional pages if nece-wary). Criteria to use this form :

2. 3. 5.

4.

One campaign contnbution in excess of $750 was made to a state or local candidate, party . pdilical committee (PAC) for either a candidate or a ballot issue, or any other organization that advocates the election or defeat of a candidate or ballot issue. Must be a permanent organization not established for election purposes . No person gave money to the organization for the purpose of the organization then using the money to make the contribution . If the contribution was made to a candidate . n o funds from s corporation or other prohibited contributor under Iowa Code section 68A,503 were used to make the contribution (this does not apply to a contribution made to a ballot issue committee) . Only one contribution to any campaign committee except for a ballot is.- ue committee was made in a calendar year . No more than one . contribution may be made to any one ballot Issue committee during a ballot issue election . if more than one contribution and the total amount of the contributions exceed $750, the organization must register with the Board as a political commiltcc (PAC) within 10 days of crossina the 5750 threshold .

Statement of Affirmation :
C ~Y Ir ,'e 1. S-lal e . affirm that the contribution reported above is accurate . I further affirm that the information oonceming the organization is correct and true to the best of my knowledge . I understand that by filing this forth, 13m subject to the laws found in Iowa Code chapter Gt3A and sdministrativc rules found in chapter 351 . I also understand that the failure to timely rile this form leads to the imposition of dvII penalties and the intentional failure to file the form may lead to additional civil and criminal sanctions . Signature ' 'Contribution' includes goods or services that are provided for five or otherwise less than fair market value . TOTAL P .01 Date

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