Professional Documents
Culture Documents
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Routine Penalties Due For Late Filed Reports Range from $20 to $800
UCTIONS ON BACK AND COMPLETE THE FOLLOWING SENTENC
I AM FILING A REPORT FOR ANNA (1) ELECTION /(2)NON-ELECTION YEAR,
Sup LiKen/tAL (report date) Indicate one
L 1-1$ U 2_
OCHECK IF AMENDMENT TO REPORT DATED - Local Committees, enter Date of EIedon
I I tz. 61-
Cj Check if this is final (termination) report and attach Notice of Dissolution Form DR-3. County a Local Committees, enter County In
(You must continue to file reports until a Notice of Dissolution Is filed.) whicp Election is held
I
**UNPAID BILLS (From Schedule D - Attach Schedule D) .. .. ..................... ........... .. .... .. ... .. . .. ... .. . ...... $ A
*IN KIND CONTRIBUTIONS (From Schedule E- Attach Schedule E) . ........ ... .. .. . . ...... ... .. . .. ........ .... ....~
/V
'*OUTSTANDING LOANS (From Schedule F - Attach Schedule F). ............ ....... ........ ........ .. ......... .....$ JA
CANDIDATE COMMITTEES ONLY:
CONSULTANT BREAKDOWN (Schedule G Attached?) YES rNO
VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H) $ A)114
For Instructions, See Back of F^-m f SCHEDULL- S
"-s I AAChi°AR'+` 1
CONTRIBUTIONS -- MONEY TAKEN IN (Rev .O66i97) RECE!P7t
,inc)ud'ang candidate's personal funds)
CHECK THIS EOX iF
COMMITITEE NAME (Must be same as On Statement Of Crganizatfon) AMENDING FORM
STATE CANDIDATES NOTE. IF .A CONTFIZUTION IS RECEIVED FROM A 3+ATEP+1C WOLtTiC .tL ACTION COMMt7rEE), L;STT1_lF PAC IDENTLFFCATCM
NUMBER AND THE PAC CHECK Num8EP IN THE DESIGNATED COLUMN . A LIST OF iD NULIBE ..AS iS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE SCARD.
CAUTION: Section C8B.32A(6), Iowa Code, prohibits the use of information copied from reports arcs statements forsolicitirg contributions or
for any corturiercial purpose by any person tinier than statutory polticai committees.
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= /o z w ~a
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SUB-TOTAL
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7OTAL (if hutpage of this schedule)
Purchases of certain campaign property costing $500 or more must also be Inventoried on Schedule H . (Refer to Schedule H instructions .)
Expenditures to personsfentities providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail Itemized on
Schedule G by the amount, purpose, and date of each type of expenditure made by the parsonlentity on behalf of the candidate's committee. (Refer to
Schedule G in structions and Iowa Ccde 66 .B(3)(i) .)
(for Schedule 8)
WOR ,TISTRUCTIONS, SEEBACK OF r,.jF?M ISCHEDULE'
IN KING
COMMITTEE NAME (Must be same as on Sfatemerrt cf Organization) 'Pev.06197) CONTRi8JTCNS
i'Ate- f~m STA TLtW .i$E
(!4 . .rM=TTCAL
1 17 CHECK THIS BCX?F
AMENDING FORM
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Il.t P itb~iCe .. PAn~y ~J'1715
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'D!sciosure law requires candidates to disclose the relationship of any relative making an in kind contribution to `he Page i of-/ _
committee. Relationship must be shown to the third degree of consanguinity (bicwod rsfstives) vid affrky. (relatives (fOr SChEUl9 ~)
b y marriage) . (See Page 2 of forms packet .) if sunlarne of a ntributor is the same as
cardidats, boat there is no
tarraillal relationship, enter 'not applicable' in the relationship column.