Bukta Polly975scanned

8/7/2019 Bukta Polly__975__scanned

1/9

FOR I NSTRUCT I ONS , SEE BACK OF FORM

C MMI T T EE NAME ( M u s t b e s ame a s o n S t a t e m r n t . o f O r g a n i z a t i o n )QLM 6 0~ r A c MPAI "

AN~~I MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y ou a r e r e p o r t i n g f o r . 1 7 1

I ) S t a t e w i d e / L e g L s l a t r v e Ca n di d a t e ( 2 ) S t a t e wi d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c al Ca n d i d a t e( 5 ) Co un t y PAC ( 6 ) B a l l o t I s s u e / F r a n c h i s e Co mmi t t e e ( 7 ) C o u n t y / C i t y C e n t r a l C ommi t t e e( 8 S u p p or t SWe o f Ca n di d a t e s - z - ~ aS I GNATURE OF T EASURER ( o r p e r s o n f i l i n g t h i s r e p o r t )

TELEPHONE

CASH

rDI SCLOSURE SUi v i MARY PAGE7Ar t ' MX1 &5 / 0 add J / Da - 1 15~' aRou t i n e P e n a l t i e s Du e F o r L a t e F i l e d Re p or t s Ra n g e f r o m $ 2 0 t o $ 8 0 0

SEE I N STRUCT I ONS ON BACK AND COMPLETE T HE FOL LOWI NG SENTENCEAM F I L I N G A

J A &1 .

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REPORT FOR A N / A ( 1 ) ELECT I ON / ( 2 ) NON- EL ECT I ON YEAR

( r e p o r t d a t e )

I n d i c a t e o n eJ AN 2 2 2 0 0 2

[ ] CHECK I F AMENDMENT T O REPORT DATED

0C h e c k i f t h i s i s f i n a l ( t e r m i n a t i o n ) r e p o r t a n d a t t a c h N o t i c e o f D i s s o l u t i o n F o r m D R- 3( Y o u m u s t c o n t i n u e t o f i l e r e p o r t s u n t i l a No t i c e o f D i s s o l u t i o n i s f i l e d . )

STATEMENT OF CASH ON HANDON HAND a t t h e b e g i n n i n g o f t h e r e p o r t i n g p e r i o d ( T h i s i s t h e t o t a lo f a l l mo n i e s h e l d b y t h e c o mm i t t e e T h i s a m o u n t MUST b e t h esame a s t h e c a s h o n h a n d a t t h e e n d o f t h e l a s t r e p o r t i n g p e r i o d ,

o r m u s t b e z e r o i f t h i s i s f i r s t r e p o r t f i l e d . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ADD TOTAL MONEY TAKEN I N T HI S PERI OD a 00S c h e d u l e A : C a s h Co n t r i b u t i o n s t o t a l ( A t t a c h S c h e d u l e A ) . . . . . . . . . . . . . . . . . . . . . .

FORMDR- 2( R e v 0 1 / 9 8 )F o r O f f i c e Us e O n l yComm xI ndex

DI SCLOSUREREPORT

A u d i t e d ~ ~ ~C o mp u t e r

L o c a l Co mmi t t e e s , e n t e r Da t e o f E l e c t i o n

C o u n t y b L o c a l Co mmi t t e e s , e n t e r Co u n t y i nwh i c h E l e c t i o n i s h e l d

DATE S I GNED


2/9

Fc r I n s t r u c t i o n s , See Back o f Fo r rCONTRI BUTI ONS - MONEYTAKENI N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f Or g a n i z a t i o n)Patq

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CmP I 9 1~STATE CANDI DATES NOTE : I F A CONTRI BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I D E NT I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARDCAUTI ON: S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a ny c ommer c i a l p ur p os e b y a ny p er s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e es .

SCHEDULEA MONETARY( Re v . 0 2 / 9 6 ) RECE I PTS0 CHECK T HI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONS HI P AMOUNTRECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECE I VED( MMI DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e )NUMBER

I D# mR~ l A l ~ ~ . " ' WRI 6 - HT / V I A $ 0 ' x . 44D CK# I 2 t a ~t -3znV0 e , 7 -6 1 , 1 ' a - f i a J A 5a !I $ I D# P I CHAPD o i - Mk y l _ A w t ~ 4 Ao I CK# / o o & a l emR aor ro01

I D#CK# ON l 1 - x / 1 ' 1 1&DCwT) Q) , 0 c 1TA1A J ~"9- a e ~

l ~z o f, o #

OWN 14 6 PAa + 4 d v v eCK# I I t v~~UI V, J r l ~. 4 - ~ ~ bM0155 ' ! ! 5 r AL10, r v ' P , 7 AL - I RVAWOI QKV 5

'0 CK# I !*4 3 - 6 6 0 ' ) , 1 1 T H 6r d. f 0Ro~K I y l An f l ~ 1 . IP l ZO-I D# 3Amer 4LI I N5MVAr : 9 ; 7 - f 1N0~~gaN ee&a/ l qgj -


3/9

Fo r I n s t r u c t i on s , Se e B a c k o f Fo r -CONTRI BUTI ONS - MONEY TAKEN I N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTF , ) NAME ( Mu s t b e s ame as on S t a t e me n t o f O r g a n i z a t i o n ) , L

161- 1 - V eopk -1; 4STATE CAND I DATES NOTE : I F A CON TRI B UT I ON I S RECE I V E D FROMA STATE PAC ( P O L I T I C A L A C T I ON C OMMI T T E E ) , L I S T THE PA C I D EN T I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COL UMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA E T H I C S AND CAMPAI GNDI SCLOSURE BOARD .CAUT I ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Co d e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e m e n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c o m m e r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o m m i t t e e s .

SCHEDULEA MONETARY( Re v . 0 2 / 9 6 ) RECE I P T S

0 1 1 CHECK T HI S BOX I FAMENDI NG FORM

DATERECEI VED

PAC I D NUMBER( i f a p p l i c a b l e )

NAMEAND ADDRESS OF CONTRI BUTOR R EL A T I ON SHI PTO CANDI DATE ' AMOUNTRECE I VED( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e )NUMBER _I D# Ok C AR1~ ~ QAl ~

u / V To 1 ~ z73I D# PhCNARD KQk 0AW-VMs' o 1 3 5 RI CK# ' 7 ~ ~ R A l 1 ?H 5T6- 7 -7 1 1 V I A Pq P - ,x~ ~

~ ) I I I D# , e . 9 , me v l 5 k s r 1 ~t l T 4 &CK# -Wo o d i - A I Vo . C AI D# . ~ . 0R 0 0 90Mq - P P , f l TD I CK# $ o~ P ~I N~ a i - v o A 1 1 AQ L ) / V r o J A 5 ,I D#

I ~ a l CK# uw~~~l ~ ) r z~ . o I I l JI UI D# MQANL " I CNLVP1GN7_CK# r 1 11 o -: 5 32NI D sue


4/9

v . . . . . r , . . . . . . . . . . . . . r r v . . . . . . . . . . . . v . . v . . . rCONTRI BUTI ONS - - MONEYTAKENI N

(

r ~ n r i d s t b ' s p o o "h i n d s )COMMI TTEE NAME ( Mu s t b e wa l e a s o n St a t e me n t o f Or g an i z a t i o n)Pal ,

M r GAmPA1~

J \ r r l CUV6 C

OCHECK T HI S BOX I FAMENDI NG FORM

AI MONETARY( Re v . O6M7) RECE I PTSSTATE CANDI DATES NOTE: I F A CONTR19 UT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE . UST THE PAC I D E NT I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A UST OF I D NUMBERS I S A V AI L A B L E FROMTHE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : S e c t i o n 6 8 8 . 3 2 A ( 6 ) . I o wa Code . p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i e d f r o m r e p o r t s an d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c o mme r c i a l p u r p o s e by an y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e es .

I " PV

DATERECEI VED PAC 1 0 NUMBER( H a p p l i c a b l e ) NAME AND ADDRESSOF CONTRI BUTOR R EL A TI O NS HI PTOCANDI DATE' AMOUNTRECEI VED J I F FOR( MM/ DD/ Y R) AND PACCHECK ( i t a p p l i c a b l e ) FUND-RAI SERNUMBER I NCOMEQ/

I D#CK#

MRs H . J . PRATr .6 o ( o P&Pl s ' r n~ &L~D n l~J ~ $0G' Dr : - i - 1 T o Z ' y 3i ~ I D# ~ l 3 1 4 4 Wf dkAr Xr r WRK4 1 CK# poi 7 , 7 1 7 N. CAP , r 0 L - ~ , i AI D - - 4 t i ) T c 4 l 0 4 0 ) ,I ~ W T o Dd ~6 2

PACI D#CK# ~ l y l 7 t I / o 0, OA; T R 1 6 ~ 7 _ ) e I Y A1 1 A h A e &jI D# &0&, 7 r c w' p y ] 5 Ai r > 1 PAL KCK# ( 0 / 7- 150 w t srv ~ ~ J ~ v ~ y r o ~~ I V ) ~W~i ' D~~ I Y I o ~ ~A 'I D# 1eVf AgN F~vNDCK# r A D5 r n o c k A I PAQTy MA raQ?5 t 1aI b i l ku k w~. k r o l _ i f s 50 ~2 II D#


5/9

FOR I N S TRUCT I ONS , SEE BACK OF FORM SCHEDULEEXPENDI TURES B MONETARY- - MONEY SPENT FROMCOMMI TTEE ACCOUNT ( R e v . 0 9 / 9 7 ) EXPENDI TURES

S TA TE PAC COMMI TT EES : NOTE : FOR CONTRI BUTI ONS MADE T O STATEWI DE OR L E G I S L A T I V E O CHECK T HI S BOX I FC A ND I D A T E S , L I S T THE CANDI DATE I D E N T I F I C AT I O N NUMBER I N THE DESI GNATED COLUMN AND THEPAC CHECK NUMBER FOR EACH EXPENDI TURE A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA AMENDI NG FORME T H I C S & CAMPAI GN DI SCL OSURE BOARD .COMMI TTEE NAME ( Mu s t b e s am e a s o n S t a t e me n t o f O r g a n i z a t i o n )KLy hi WG/yl 0-ow~ V5~; -

CANDI DATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e me n t ) WAS MADE( MM/ D D / Y R ) AND PACCHECKNUMBERf o f I D# tG l O' T ~ c K# D ~ 1VOI A~A ~4

~ z 7 / a I D# r Ni ~ ~ ~ c om~~~r P I rw~ -_4 . L D( ) 1 ) , ~ - r : 5 ; r - o v ~ c ~ ~ ' ~2 ml e5C4*1 c ~ 7 1 CK# D i e , - _ e ~ mc v n ' l ,6 ~ 7/ - / A ~M-A uv A~~R ssA/ 1 1 6 , / I D# n 1 / 1 V A DV P k T I I ' L L

~c l r 7 CK# k j 1 Vr oA'I1 A 5 z

I D# 0 1 / , 7 . C ' L L t 1 LA12 G~ ~1. L ~ ~~ l G~ l 'P D ~ ~o~' y 1G : I o I CK#

' ~ ' r J l 9 Of I D# o , , ! ,ooi

l i L GCj o q CK# P. o

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I D# j , ! ~G~. t kL 0


6/9

FOR I NSTRUCTI ONS, SEE BACK OF FORM SCHEDULEEXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT ( Re v . 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE: FORCONTRI BUTI ONSMADE TO STATEWI DEOR L EGI S LAT I VECANDI DATES, L I ST THE CANDI DATE I DENT I F I CATI ON NUMBER I N THE DESI GNATED COLUMN AND THE C ] CHECKTHI S BOXI FPACCHECK NUMBER FOR EACH EXPENDI TURE . A L I ST OF I D NUMBERS I S AVA I LABLE FROM THE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD.COMMI TTEENAME ( Mu s t b e s ame a s o n St a t e me nt o f O r g a n i z a t i o n )I oMU

CANDI DATE NAME ANDADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( Di s b u r s e me nt ) WASMADE( MM/ DD/ YR) AND PACCHECKNUMBER

CK# 0 ~ ~ ) C6 1 7 7 1 ~~ - 6 r _ _ , 0 A ) Z $ .I T3 & 1 6 1 1 1 I D# o l ~ ' , - s ZD ~ t i ~ ~7 ) S) 4CCK# oG . ) l \ r - r O l U I Al I I D# ~, y , ~ Zl - 1 , ~ LAk C2~LZ - f t ~ A' 2 5P . ( - ) . J ? ? 0 ~ 4 - 10647CK# C ~ ~ I Q ' R ~ i ~ ~ I` ~ 1 1 1 1 0 _ 1 I D# av4A

# o l p _ p Ap - R ~ P i o I 7 i Ai 6~l 6l 01 I D# 0, y,CVZ~VVARR010 ~~I ~1WcDl

I D# ~WppAT 1 L Q 0 , x , 4 A 7 / 4 / 1, 1CK# ! ~


7/9

FOR I N STRUCT I ONS , SEE BACK OF FORM SCHEDULEEXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI T T EE ACCOUNT ( R e v . 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEE S : NOTE : FORCONTRI BUTI ONS MADE TO STATEWI DE OR L E G I S L A T I V EC A ND I D A T E S , L I S T THE C A ND I D A T E I D E N T I F I C A T I ON NUMBER I N THE DESI GNATED COLUMN AND THE 0 CHECK THI S BOX I FPAC CHECK NUMBER FOREACH EXPENDI TURE . A L I S T OF I D NUMBERS I S A V A I L A B L E FROMTHE I OWA AMENDI NG FORME T H I C S & CAMPAI GN D I S C L O SU R E BOARD .COMMI TTEE NAME ( Mu s t b e s am e a s o n S t a t e me n t o f O r g a n i z a t i o n )~ o L L y i 3 NTA t 1- MOM64 1 Vr I 5,CANDI DATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE( MM / D DI Y R ) AND PA CCHECK

NUMBERI D# - A~ D,

G~LLU11 6 1 0 f pC 4 * 1 0 CK# JeDf .00~s $I D#CK#I D#CK#I D#CK#I D#

CK#I D#CK#


8/9

FOR I NSTRUCTI ONS, SEE BACK OF FORMCOMMI TT EE NAME ( Mu s t b e same a s o n St a t eme n t o f O r g a n i z a t i o n )PaN~ ~~*A aAW1611 - ~ - - q 1 7 t , 7 "

SCHEDULEE

I N K I ND( R e v . 0 2 / 9 6 ) I CONTRI BUT I ONS

pCHECK T HI S BOX I FAMENDI NG FORM

DATERECEI VED

( MM/ DD/ YR)NAME AND ADDRESSOF CONTRI BUTOR

RELAT I ONSHI P TOCANDI DATE - ( i fa p p l i c a b l e )

DESCR I PT I ONOF I N K I NDCONTRI BUT I ON

EST I MATED F AI RMARKET VALUE

~ 1 3 ~ I QOM I UKYAGoOTH 3zAW - Sr~ i" 5 2 7 3 I w o 2 / ~; 7gM~. 4 0 . ~z ?


9/9

FORI NSTRUCTI ONS, SEE BACK OF FORM

COMMI TTEE NAME( Mus t b e same a s o n S t a t e me n t o f O r g a n i z a t i o n )?0W.

v - A r C~mVA

9~NOTE : T h i s s c h e d u l e r e p o r t s money l o a n e d t o t h e c o mmi t t e e wh i c h i s d e p o s i t e d i n t h e c o mmi t t e e a c c o u n tTOTAL UNPAI D LOANS FROMLAST REPORTI NG PERI OD $ ~-PART - MONETARY LOANS RECEI VED THI S REPORTI NG PERI OD( O r i g i n a l s o u r c e o f l o a n , s u c h a s a b a n k , mu s t b e s h ow n i f a t h i r d p a r t y i si n v o l v e d I n c l u d e l o a n s f r o m c a n d i d a t e ' s p e r s o n a l f u n d s . )

TOTAL ( PART I )

' D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mmi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v ema k i n g a c o n t r i b u t i o n t o t h e c o mmi t t e e R e l a t i o n s h i p must b e shown t o t h e t h i r d d e g r e e o fc o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b y m a r r i a g e ) ( S e e Pa g e 2 o f f o r msp a c k e t . ) I f s u r n ame o f c o n t r i b u t o r i s t h e same a s c a n d i d a t e , b u t t h e r e i s n o f a mi l i a lr e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn when i t a p p l i e s

PART I I - MONETARY LOAN REPAYMENTS MADE_THI S REPORTI NG PERI OD( L o a n s f o r g i v e n must b e r e p o r t e d o n Sc h ed u l e E - - I n - k i n d C o n t r i b u t i o n s . )

TOTAL CASH REPAYMENTS ( PART l l )

$- - 0-

F r o m Sc h e d u l e F - - TOTAL LOANS FORGI VEN

$ - 4 -

TOTAL OUTSTANDI NG LOANS END OF REPORT PERI OD

$1

Pa g e

) o f( f o r S c he d u l e F )

SCHEDULEF LOANS( R e v 0 2 / 9 6 ) RECEI VED& REPAI D[ ~ CHECK THI S BOX I FAMENDI NG FORM

DATERECEI VED( MM/ DD/ YR)

NAME AND ADDRESS OF LENDER( i n c l u d e E n d o r s e r ' s Name, I f A p p l i c a b l e )

RELAT I ONSHI PTO CANDI DATE( I f A p p l i c a b l e " )AMOUNTOF LOAN

41

VKTA&o4Po~L y ~~ s r&DN ' T o l V A

$DATE PAI D( MM/ DDI YR)

NAME ANDADDRESS OF LENDER( I n c l u d e E n d o r s e r ' s Name, I f A p p l i c a b l e )

RELATI ONSHI PTO CANDI DATE'( I f A p p l i c a b l e )AMOUNTREPAI D

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Bukta Polly__975__scanned

Bukta Polly975scanned