Quirk Brian1255scanned

8/7/2019 Quirk Brian__1255__scanned

1/11

FORI NSTRUCTI ONS, SE E BACK OF FOP

DI SCL OSURE SUMMARYPAGE J AN 1 t i c u u [COMMI TT EE NAME ( M u s t b e s ame 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 : , % . f

I MPORTANT: I n d i c a t e t y p e o f c o mmi t t e e y o u a r e r e p o r t i n g f o r : a( t ) S t a t e w i d " s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e( 5 ) C o u n t y PAC ( 6 ) B a l l o t I S S U O / F r a n c h i s e C o mmi t t e e ( 7 ) C o u n t y / C i t y C e n t r a l C o mmi t t e e( a ) S t o o f C a n d i d a t e s

Z , 4 1 - 3 9 / j - : 2 , SLR Ca Z. -S I G URE OF TR SU R ( 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 DATE SI GNEDRou t i n e P e n a l t i e s Du e Fo r L a t e F i l e d Re p or t s R a n g e f r o m $ 2 0 t o $ 8 0 0

SEE I NSTRUCTI ONS ON BACK ANDCOMPLETE THE FOLL OWI NG SENTENCE :AM F I L I N G A SC o REPORT FOR A N/ A ( 1 ) ELECTI ON / ( 2 ) NON- ELECT I ON YEAR .

( r e p o r t d a t e ) I n d i c a t e o n eOCHECK I F AMENDMENT TO REPORT DATEDOC 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 N o 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 HANDCASH ON 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . l . l . . : . . . . ( . . . . . $

ADD TOTAL MONEY TAKEN I N T HI S PERI OD - 3 17 0 , 0 0S c h e d u l e A : C a s h C o 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 )S c h e d u l e F L o a n s R e c e i v e d t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c h e d u l e H T o t a l S a l e s o f Ca mp a i g n P r o p e r t y ( A t t a c h S c h e d u l e H ) . . . . . . . . . . . . . . . . . . . . . . . . . . .

( S c h e d u l e H a o o l i e s t o C a n d i d a t e s ' Comm i t t e e s O n l y )

S c h e d u l e F : L o a n Re p a y me n t s t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . .CASH ON HAND a t t h e e n d o f t h i s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t , b a l a n c e m u s t j f

b e z e r o ) ( A t t a c h D R - 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v . . . . . . . . . . $

FORMDR- 2 I DI SCLOSURE( R e v . 0 1 / 9 8 ) REPORTF O f f i c e n lc o mm. eU i d e x e ~A u d i t e d

L o c a l C o mmi t t e e s , e n t e r D a t e o f E l e c t i o nC o u n t y & L o c a l C o mmi t t e e s , e n t e r C o u n t y i nw h i c h E l e c t i o n i s h e l d

SUB- TOTAL . . . . . . S ' 9 0SUBTRACT TOTAL MONEY SPENT T HI S PERI OD s ~ 1 3 / Os - q , 5 - ( f 1 n 8 y . , s 4S c h e d u l e B E x p e n d i t u r e s t o t a l ( A t t a c h S c h e d u l e B ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

UNPAI D B I L L S ( F r o m S c h e d u l e D - A t t a c h S c h e d u l e D ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ~U -I N KI ND CONTRI BUTI ONS ( F r o m S c h e d u l e E - A t t a c h S c h e d u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $OUTSTANDI NG LOANS ( F r o m S c h e d u l e F - A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S l J , O0 _CANDI DATE COMMI TTEES ONLYCONSULTANT BREAKDOWN ( S c h e d u l e G A t t a c h e d ? ) YES NOVALUE OF CAMPAI GN PROPERTY ( F r o m S c h e d u l e H - A t t a c h S c h e d u l e H )


2/11

For I n st r u c t i o ns , See Back o f Fo . .CONTRI 1317T1 0NS -MONEYTAKENI N

( k + d ud l n g c ar d d e t e ' s p e r s o n a l l u xe )COMMTTEENAME( Mu s t be s ans as o n St a t e n l s n t o f Or g a n i z a t i o n)

SCHEDULEA I MONETARY( Rw. 0 6 l t i 7 ) RECEI PTS0CHECK T HI S BOXAMENDI NGFORMSTATECANDI DATES NOTE I F ACONTRBI JT I ON I S RECEI VED FROM ASTATEPAC( P OL I T I C AL ACTI ONCOMMI TTEE) . USTTHE PAC I DENT I F I CAT I ONNUMBERANDTHEPACCHECKNUMBER I N THE DESI GNATED COLUMN. AUSTOF 1 0 NUMBERS I S AVAXAS LE FROM THE I OWA ETHI CS ANDCAMPAI GNDI SCLOSURE BOARD.CAUTI ON: Se c t i o n 68B. 3 2A ( 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 or ma t i on c op i e d f r o m r e p o r t s and s t a t e me n t s f o r s o l i c i t i n g c on t r i b ut i o nsf o r any c omr t l e r d a l p u r p o s e b y any 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 d c a l c o nv Nt t e e s .

D r s c i o s u r e l a w r e g w r e s c a n d i d a t e c ommi 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 ny r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h e: Dmmi l 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 f c o n sa n gwn r t y ( b l o o d r e l a t i v e s ) a nd a f f i n i t y ( r e l a t i v e s b y a r n a g e ) ( Se e P a g e 2 o f f o r ms p a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e s a m e a s c a nd i d a t e . b u t t h e r e i s no, a r n r l i a l r 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 ( I a Sc h e d u l e A )

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELATI ONS P AMOUNT JRECEI VED ( M a p p l i c a b l e ) TO CANDIDAE- RECEI VED F( MMOD/ YR) ANDPACCHECK ( i f a pp l i c ab l e ) RNUMBER I NI D S E I l e e n ken- e ,~V Ave! I l d l e f CKS Ll 09 ~V . &Ae s - 4i t u f SI , , , P f 0 . 1 1 , . T 4 SOt ' S~ Z5e r rI DS , Tc a , . a R. . ( 5we . r s o CKS 15Ashl rs t ~ na ( Avee ! v . . - . v n r . . 1 ~ . bS v

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3/11

Fo r I n s t r u c t i o n s , Se e Back o f , mCONTR113 t 7TI ONS - - MONEYTAKEN I N( f n d u d ng c a n d d a f e ' s p e r s o n a l l a n d s )C0 1 A r r 1 1 T T E E NAME ( Mu s t b e s ame a s on Sb t e r r l e n t dOr g a n i z a t i on )

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SCHEDULEA MONETA( Re v . 0 6 4 1 7 ) I R ECE I PQCHECK T HI S BOAMENDI NG FOR

S T A T E CANDI DA T E S NOTE: I F A CONTR I BUT I ON I S RECE I V ED FROM A STATE PA C ( P OL I T I C A L ACT I ON COMMI T TEE ) , US T THE PA C I D E NT I F I C A T I O NNUMBER AND T HE PAC CHECK NUMBER I N THE DES I GNATED COLUMN . A UST OF 1 0 NUMBERS I S A V A I L A B L E FROM T HE I OWA ETHI CS AND CAMPAI GDI SCLOSURE BOARD .CAUTI ON: S e c t i o n 6 8 8 . 3 2 A ( 6 ) . I o wa Cod 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 me 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 of o r a r t y , c o mme r c i a l p u r p o s 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 i l i c a l c o r t v n i t t e e s .

D i s c l o s u r e t a w r e q u i r e s c a n d i d a t e c o mm i 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 e ma k i n g a c o n t r i b u t i o n t o t h e: ' a mmd l " R e l a t i o n s h i p m u s t b e s h own t o t h e t h u d d e g r e e o f c o n s a n g u r n r l 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- a r n a g e ) ( S e e P a g e 2 o f f o r m s p a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e s am e a s c a n d i d a t e . b u t t h e r e i s n o, a mr l i a l r 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 Pa g e __Z___ o f ,( l o t Sc h e d ul e A )

DATE PA C I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR R EL A T I O NSHI P AMOUNTR E CE I V E D ( I f a p p l i c a b l e ) TO CANDI DA TE ' R E CE I V E D( MM/ DDJYR ) ANDPACCHECK ( i f a p p l i c a b l e )NUMBER1 D" c 7 e r n 6777

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4/11

Fo r I n s t r u c t i o n s , See Back o f , emCONTRI BUTI ONS - MONEYTAKENI N( Y n d u d k V c a n d d e t e ' s p e r s o n a l l a n d s )COMMI TTEE NAME ( Mu s t b e s ame a s on S t a t e n l e n t o f OWn i z a t l o n )

FAMEWAVSTATE CANDI DATES NOTE : 1 1 : A CONTRI BUT I ON I S RECEI VED FROM A STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , UST THE PAC I D E NT I F I C A T I O NNI AABER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A UST OF I D NUL43ERS I S A VA I UI B L E FROMTHE I OWA ETHI CS AND CAuPA* NDI 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 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 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 of o r a n y c o mme r c i a l p u r p o s e b y a ny 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 Y t l m l c o n u n l t t e e s .

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 mm i 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 e ma k i n g a c o n l r i b u t i o n t o t h e: ~ mmd t e e R e l a t i o n s h i p mu s t b e s how n t o t h e t h i r d d e g r e e o f c 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' ^ a r n a g e l ( S e e P a g e 2 o f f o r m s p a c k e t . ) I f s u r n a m e o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e . b u t t h e r e i s n ol a m r l i a l r 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 P a g e3_o f( l o t S c h e d u l e A )

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5/11

Fo r I n s t r u c t i o n s , Se e B a c k o f F o i . ,CONTRN30 TI ONS - MONEY TAKEN I N( I n c l u d i n g c a n d d e f e s p e r s o n a l l u n d e )COMMI TTEE NAME ( M u s t b e same e s o n S t a t e me n t o f O r g a r g z a t l o n )

SCHEDULEA Mo NETAR, r( Re v . OGMT) RECEI PTSCHECK THI S BOX IAMENDI NG FORM

STATE CANDI DATES NOTE I F A CONTRI BUTI ON I S RECEI VED F ROM A STATE PAC ( P O L I T I C AL ACTI ON COMMI TTEE) . UST THE PAC I D E NT I F I C A T I O NNUMBER AND THE PACCHECK NUMBER I N THE DESI GNATED COLUMN . A UST OF 1 0 NUMBERS I S A V A L A 1 3 L E FROMTHE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) . I o wa Cod 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 me 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 of o r a n y c o mr n e r d 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 d ml c o m i r l i t t e e s .

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 mm i 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 e ma k i n g a c o n t r i b u t i o n t o t h e: x nm l l e e R e l a t i o n s h i p m u s t b e s h o w n t o t h e t h u d d e g r e e o f c o n s a n g W n r 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 a r n a g e ) ( Se e Page Y o f f o r m s p a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e s ame a s C a n d i d a t e . b u t t h e r e i s n o _I s - l i a l r e l a t i o n s h i p . e n t e r ' n o l 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 Co l umn ( l o , Sc h e du l e A )Page _~___ o f

DATE PAC I D NUMBER NAME AND ADDRESS OFCONTRI BUTOR RELATI ONSHI P AMOUNT J IRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECE I VED F( MMI DDI YR) AND PAC CHECK ( i f a p p l i c a b l e ) RANUMBER I NI D x T~ G ~ e - rn l ~ o f .3 SCKx d vYGl kI Dx f l ~ t d ~~ ; ~ t ~ 5~d 1 l ) / 0 / CKx / 70 S / SS 4 16ZS_I Dx l J ; , a d ' ~ j h e ~ ~l c r - n e

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6/11

P ' o r I n s t r u c t i o n s , Se e Ba c k o f F_aCONTRI BUTI ONS - MONEYTAKEN I N( I n d u d n g c a n d d r t i s p e r s o n a l f u n d s )COMMI TTEENAME ( M u s t b e s a n s 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 )

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SCHEDULEA MONETARY( R e v . Damn I RECEI PTSCHECK T HI S BOXAMENDI NG FORM

STATE CANDI DATES NOTE I F A C ON T R I B UT I O N I S R E CE I V E D FROMA S T A T E PAC ( P OL I T I C AL A C T I O N C0 1 MA I T T E E ) . US T T HE PAC I DE NT I F I C A T I O NNUMBER AND T HE PAC CHECK NUMBER I N T HE D E S I G N AT E D COLUMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROMTHE I OWA E T H I C S AND CM, t pAnmD I S C L O S U RE BOARD.CAUTI ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) . I o w a C o 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 sf o r a n y c o m m e r c i a l p u r p o s e b y any 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 .

D i s O 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 mm i 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 e m a k i n g a c o n t r i b u t i o n t o t h e: * ) m m a t e e R e l a t i o n a h r p m u s t b e s h o w n t o t h e t h u d d e g r e e o f c 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- a r n a g o ) ( S e e P a g e 7 o f f o r m s p a c k e t . ) I t s u r n a m e o f c o n t r i b u t o r i s t h e s a m e a s c a n d i d a t e . b u t t h e r e i s n o, a m r l i a l r 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 p a g e _ ! ! ~ _ o f ,( l a S c h e d u l e A )

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT JRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED( MMI D Df Y R ) ANDPAC CHECK ( i f a p p l i c a b l e ) RNUMBER II D S ( ~ C~r r f h t 6 / f ? l l auSe %l l l B

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7/11

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

( k c du dr q c a nd de t e ' s p e r s o n a l h i n d s )I COMMI TTEENAME( Mu s t be sans as o + 1 St a t e v ne nt o f Or g a ni z a t i o n)

j GYP ? l ?ePFPSC r x /.

D i s c l o s u r e l a w r e q u i r e s c a nd 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 e ma k i n g a c o n t r i b u t i o n t o t h e: - 3 mmi f l e e R e l a t i o n s h i p must b e s h own t o t h e t h ud d e g r e e o f c o n s a n g u r n r 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 yma r r i a g e ) ( Se e Pa g e 2 o f f o r ms p a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e same a s c a nd i d a t e . b u t t h er e i s nof a r n r f i a l r 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

STATE CANDI DATES NOTE I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC( POL I T I CAL ACTI ON COMMI TTEE ) . UST THE PAC I DENT I F I CATI ONNUMBERAND THEPACCHECK NUMBER I N THE DESI GNATED COLUMN. AUST OF I D NULABEAS I S AVA I LABLE FROU THE I OWA ETHI CS ANDCAMPAI GNDI SCLOSURE BOARD.CAUTI ON : Se c t i on 68B. 3 2 A( 6 ) . I o wa Code . p r o h i b i t s t h e us e o f i n f o r ma t i o n c op i e d f r o m r e p o r t s and s t a l e r n en t s f o r s o l i c i t i n g c on t r i b ut i o ns orf o r any t o r n r n e r c i a l p u r p o s e b y any 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 on wn i t l e e s .

P a g e -~__o f( f o r S ch e d u l e A)

SCHEDULEA MONETARY( Re v . 06W) RECEI PTS0 CHECK THI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESSOF CONTRI BUTOR RELATI ONSHI P AMOUNT J I FRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE- RECEI VED FUN( MMI DD/ YR) AND PACCHECK ( i f a pp l i c ab l e ) RAI SNUMBER I NCOi o n c i ; f z sl l ~ ; ' V Q t / o / CKU L~ 5 L ~ n l ' t v C '. S Z

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8/11

Fo r I n s t r u c t i o n s , Se e Bac k o f FL - . , ICONTRI EI UTI ONS - MONEYTAKEN I N( Y n d u d n q c a n d d a t i s p e r s o n a l A s d s )COMMI TTEENAME ( Mu s t b e same a s o n S t a t e r n a n t o f O r g a n i z a t i o n )

Vdr ' l an 0 , , -a S- bj x e , 4 e`STATE CANDI DATES NOTE: I F A C ON T R I B U T I O N I S R E CE I V E D FROM A S TA TE PA C ( P O UT I C AL A CT I O N C O MMI T T E E ) . UST THE PAC I D EN T I F I C AT I O NNUMBER AND T HE PAC CHECK NUMBER I N T HE D E S I G N AT E D COLUMN. A L I S T OF I D NI TERS I S A VA J L I B L E FROM THE I OWA E T H I C S AND CAMPAI GND I S C L O S U RE BOARD .CAUTI ON : S e c t i o n 6 8 8 . 3 2 A ( 6 ) . I o w a C o 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 an 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 sf o r a n y c o r n me 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 mm i t t e e s .

SCHEDULEA MONETARY( R e v . gQmn RECEI PTSQCHECK T HI S BOXAMENDI NG FORM

D i s c l o s u r e l a w r e q u i r e s c a nd i d a t e c o m m i 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 e ma k i n g a c o n t r i b u t i o n t o t h e: y r m m r t l s e R e l a t i o n s h i p m u s t b e s h o w n t o t h e t h u d d e g r e e o f c o n s a n g o r u t y ( Mo 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- a r n a g e ) ( S e e P a g e 2 o f f o r m s p a c k e t . ) I f s u r n a m e o f c o n t r i b u t o r i s t h e s am e a s c a n d i d a t e . b u t t h e r e i s n ol a m r l i a l r e l a t i o n s h i p e n t e r ' n o t a p p 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 P a g e7_ o f( t o t S c h e d u l e A )

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT JRECEI VED ( 8 apOcaus ) TOCANDI DATE' RECEI VED( MhVDD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RNUMBER II D r l - D Y I 0 U. t YL E2 . ,CKr 2 - 0 Ma 1 n $ IO

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9/11

` Fo r I n s t r u c t i o n s , Se e Ba c k o f F .CONTRI BUTI ONS - MONEY TAKEN I N( I n c k i d n 0 c a n d d a l e ' s p e r s on a l k i n d s )COMMI TTEE NAME ( Mu s t be sans a s o n S t a l e + n s n t o / Or g a n i z a t i o n )

STATE CANDI DATES NOTE I F A CONTRI BUT I ON I S RECENED FROM A STATE PA C ( P OL R I C AL ACTI ON COMMI TTEE ) . US T THE PAC MENT * I CAT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A UST OF I D NUMBERS I S AVMA13LE FROM THE I OWA ETHI CS AND CAMPAKs mDI SCLOSURE BOARD .CAUTI ON : S e c t i o n 6 8 8 . 3 2 4 ( 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 op i ed f r o m r e p o r t s and 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 nf o r a i r y c omme r c i a l p u r p o s e b y any 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 Y t i c a l c o mmi t t e es .

D t s c i o s u r e l a w r e p w r e s c a n d i d a t e c o mm i 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 e ma k i n g a c o n t r i b u t i o n t o t h e: 7 - ma t e r R e l a t i o n s h i p m u s t b e s h o wn t o t h e t h u d d e g r e e o r c o n s a n g u r w 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 ym a r r i a g e ) ( S e e P a g e 2 o f l o a n : p a c k e t . ) I f s u r n a me o f c o n l r i b u l o r i s t h e s ame a s c a n d i d a t e . b u t t h e r e I S n o Page 9, _ o f i~l a m r l i a l r 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 ( l o t Sc h e d ul e A )

SCHEDULEA 1. 1 0 N ET A A( Re v . 0 6 4 1 7 ) RECFJF r T0 CHECK T HI S BOXAMENDI NG FORM

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT JRECE I VED ( I f a p p l i c a b l e ) TO CANDI DATE ' RECE I VED( MMOD/ YR) AND PAC CHECK ( i f a p p l i c a b l e )NUMBER II DS k M

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10/11

Fo f I n s t r u c t i o n s , Se e Back o f Fo r n ,CONTRI B t 7T10 NS - MONEY TAKEN I N( l n d u d l n g c a n d d i t e ' s p e r s o n a l f u n d s )COMMf TTEENAME ( Must be same a s o n S t a t s ma n f dO r g a n t z e N o r t )

SCHEDULEA MONETARY( R e v . 0 6 1 9 7 ) I RECEI PTS( ] CHECK T H I S BOX I FAMENDI NG FORM

STATECANDI DATES NOTE O F A C ON T R I B U T I O N I S R E CE I V E D FROMA S T A T E PAC ( P O L I T I C A L A C T I O N C O MM I T T E E ) . UST THE PAC I D EN T I F I C A T I O NNUMBEA AND T H E P A C CHECX NUMBER I N T HE D E S I GN A T E D COL UMN. A L I S T OF 1 0 NUMBERS I S A V A I L A B L E FROM T HE I OWA E T H I C S ANDCAMPAI GND I S C L O S UR E BOARD.CAUTI ON: S e c t i o n 6 8 8 . 3 2 A ( B ) . I o w a C o 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 an d s t a t e m e n t s f o r s o t i c i t i n p c o n t r i b u t i o n s o rf o r an y c o mm 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 t k s l c o mm i t t e e s .

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 mm i 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 e m a k i n g a c o n t r i b u t i o n t o t h e: . ) mm g l e e R e l a t i o n s h i p m u s t b e s h o w n t o t h e Mi d d e g r e e o f c o n s a n g u a r w 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 a r n a g e ) ( S e e P a g e 2 o f f o r m s p a c k e t . ) I f s u r n a m e o f c o n t r i b u t o r i s t h e s am e a s c a n d i d a t e b u t t h e r e i s n ol a m r l t a l r 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 mnPage___ O f 9- . .( f o r S c h e d u l e A )

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT J I FRECEI VED ( I I a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUN( MMI D D/ Y R) ANDPAC CHECK ( i f a p p l i c a b l e ) RAI SNUMBER I NCOI I l Z 7 l

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11/11

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