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f : ~ r I NSTRUCTI ONS . SEE BACK 7 : FORM
[ DI SCLOSURE - , JMMARYPAGE
I AM F I L I NGA
CANDI DATE COMMI TTEES ONLY :
Ca n d i d a t e Na me
P o f , ~ i c a l P a r t y
` DAAJ R4SmusseAI
KI t t 6 / ; ( Ak
O f f i c e So u g h t
S a l e. k - 4 s 2 1 f z f ' 4 '
1 i V CD i s t r i c t ( i f Se n a t e o r H o u s e )
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 ) S t a t e w i d e / L e g i 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 ( o" ) B a l l o t I s s u e / F r a n c h i s e C o mmi t t e e ( 7 ) C o u n t y i C i t y C e n t r a l C o mmi t t e e( a ) Su p p o r t S l a t e o f C a n d i d a t e s
3 / 9
3 3 y - X390
SI GNATURE OF TREASURER ( o r p e r s o n p i l i n g t h i s r e p o r t )
TELEPHONE
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 .( Yo u must 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 HAND
CASH ON HAND a t t h e b e gi 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 l o f a l l mon i e s h e l db y t h e c o mmi t t e e . T h i s amo u n t MUST b e t h e s a me a s t h e c a s h o n h a n d a t t h e e n d
FORM
( Re v . 0 1 / 2 0 01 )
F o r Of f i c s t l s e On l y
Comm. #
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SEE I NSTRUCTI ONS ON HACK AND COMPLETE THE FOLLOWI NG SENTENCE :
REPORT FORAN/ 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 e
CHECK I F AMENDMENT TO REPORT DATED 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 n
C 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
p , o v
DI SCLOSURE
REPORT
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F o r l n s t r u c t f c n s , Se e EBCk o f Fo r m
CONTRI BUTI ONS - MCNE" 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 TTEE ; N AME ( M u s t b e same a s o n S t a t e m e n t o f O r g a n i z a t i o n )
4 11~~ c
- S / h l . ~ s s c ° ~ t~ -Su1c~
use
SCHEDULE
( R e vC I ~ _
MCNE- ARY! i " REc s: P T _ q
CHECK T H I S SOX i FAMENDI NG FORM
I
S T A T E C A N DI D ATE S E M C i F _ I F A CO NT R I B U T I O N I S R E C- E V E D F R O M A S T A T E P A C ( P O L I T I C A L A CT I O N CCMMf T I ? 9 , L I S T TH E P A C I D E I T I F I C A T I O NN U M B E R AND T H E P A C C H E C K N U M B E R I N T H E D ES I G N A T E D C O L U M N A L I S T O F I D N U M B E R S I S A VA I L A B L E F R O M ' T E l E I O WA E T H I CS A N D C AMP A I G ND I S C L O S U R E B O A R D .
CAU T I ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , l o w s , 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 s o rf o r a n y c o r n m e r c i a i 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 .
DATE PA C I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT d I F FOR
RECE I VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND- .
( MMI DD/ YR) AND PAC CHECK ( I f a p p l i c a b e ) RAI SERNUMBER I NCOME
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" F o r I n s t r u c t i o n s , S e e S a c k o f F o r m
CCNT- I H l 3 T I C N S - MCNEY 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 )
C O MMI T i I E E MA ME ( M u s t b e s a me a s o n S t a t e m e n t o f O r g a n i z a t i o n )
M C N E T A R YR E C c : P T S
C H E C K T H I S B OX I FA ME N D I N G F O R M
S T A T E J . A I D I D A i E S
I F A C O N T R I B U T I O N I S R E C - V E D F R O M A S T A T E P A C ( P O L I T I C A L A C T I O N C O M M I T r E E ) , L I S T T H E P A C I D E N T t F I C A T I O N
N U M B E R A N D T H E P A C C R E - - < N UMBE R I N T H E D E S I G N A T E D C O L U M N . A L I S T O F I D N U M B E R S I S A V A I L A B L E F R O M T 1 4 S I O W A E T H I C S A N D C A M P A I G ND I S C L O S U R E BOARD .
C A U T I 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 s o r` o r a n 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 .
DATE PACI D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT J I F FOR
RECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE ' RECEI VED FUND_
( MMI DD/ YR) ANDPAC CHECK ( i f a p p l i c a b l e ) RA I S I NNUMBER I NCOME
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F o r I n s t r u c t i o n s , Se e B a c k o f F o r
CCNT RI BI J T I CNS - AWNEYTAKEN 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 TT EE NAME ( M u s t b e s ame a s o n S t a t e m n n t o f o r g a n i z a t i o n )
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) 69- 6 pw&c~t
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SCHEDULE
} IMCNETARY
( Re v . 0 6 9 7
RECSPTS
( Z3CHECK T HI S BOX I FAMENDI NG FORMA
STATE CANDI DATES NOTE : I F A CONTR I BUT I ON I S RECE I VED FROM A STATE PAC ( P OL I T I C AL ACT I ON COMI AI T TE ! , UST THE PAC I DE NT I F I CAT I ONNUMBER AND THE PAC CHECK NUMBER I N T HE DESI GNATED COLUMN . A L I ST OF I D NUMBERS I S AVA I LABLE FROMTHE I OWA E THI CS AND CAMPAI GNDI SCLOSURE BOARD .
CAUTI ON : Se c t i o n 6 8B . 3 2 A ( 6 ) , I o wa 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 op 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 o r n me n 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 an s t a t u t o r y p o l i t i c a l c o mmi t t e e s .
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR R EL A T I ON S HI P AMOUNT J i F FCR
RECEI VED ( { f a p p Uc a b l e )( MMI DD/ Y R) AND PAC CHECK
TO CANDI DATE ' RECEI VED
( l f a p p l i c a b l e )
FUND..
NUMBER RAI SERI NCOME
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Fo r l n s t r u c t ( I On s , See Back o f Fo r
ccNTRI BLMCNS- MONEYTAKEN 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 TTEE NAME( Mu s t b e s ame a s o n St a t e me n t o r Or g an i z a t i on )
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I MONE' ARY
( Re v . 0 6 / 9 7 )
RECZPr S
CHECKT HI S BCX i FAMENDI NG FORM
STATE CANDI DATES , 1 i O T E I F A CONTRI BUT I ON I S REC- VEDFROMA STATE PAC (POUTONC OM1 A I T r E E ) , USTTHE PAC I DENT I F I CAT I ON( UMBER AND THE PAC CHECKNUMBER I N THE DESI GNATEDCOLUMN. A USTOF I D NUMBERS I S AVA I LABLE FROMTHE I OWA c 7 H i CS ANDCAMPAI GNDI SCL OSURE BOARD.
CAUTI ON: Se 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 an y c omme r c i a l p u r p o s e b y a n y 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 .
DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR R EL A T I ONS HI P AMOUNT J I F FCR
RECEI VED Of a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUNO-
( MM/ DD/ YR ) AND PACCHECK ( i f a p p l i c a b l e ) RAI S ER. - NUMBER I NCOME
I D# r '
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Fo r I n s t r u c t i o n s , See Back c r Fo r
CONTRI BUTI ONS - j 1 4On 1 E V 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 TTEE yAME( Mu s t b e s ame a s o n St a t e me n t o r Or g a ni z a t i o n)
l C7U~ S ' oA: 5 ~ 74o zQCo t r . ,
CHECK T HI S BOX I FAMENDI NG FOR I A
STATE CANDI DATES NOTM - I F A CONTRI BUT I ON I S RECEI VED FROMA STATE PA C ( POUnCAL ACT I ON COMMI TTEE) , L I S T T HE PAC I DENT I F I CAT I ONNUMBER AND THE PAC CHECKNUMBER I N THE DESI GNATED COLUMN. A L I ST OF I D NUMBERS I S AVA I LABLE FROMTHE I OWA - c T H I C S AND CAMPAI GNDI SCLOSURE BOARD .
CAUTI ON : Se ct 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 op 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 r t s o rf o r an y c omme r c i a l p u r p o s e b y an y p e r s o n o t h er 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 e s .
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELA T I ON SHI P AMOUNT W I F FCRRECEI VED O f a p p l i c a b l e ) TO CANDI DATE' RECEI VED
( MMI DD/ YR) AND PAC CHECK ( 1 1 a p p l i c a b l e ) RAI SERNUMBER
I NCOME
I D# DC7y ~S ~~L l J Cc 2 i ~ C~ .
l a l 3 / f i r C33~~
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Fo r I n s t r u c t i on s , See Back oT f o r
C- NTRI ELMONS - MONEYTAKEN 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 ( a n d s )
COMMI T ' i E t , ' . MAME( ' Mu s t be s ame a s o n St a t e me n t o f Or g a n i z a t i o n)
~r/ r7US o
SCHEDULE
I MONETARY( Re v . o s l s
RECEMr S
! ~ CHECK T HI S BOX I FI D/AMENDI NG FOR I I
STATE CANDI DATES NOTE I F A CONTR I BUT I ON 1 S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI T TEE) . UST THE PAC I D E NI T I F I C A T I O NNUMBER AND THE PAC CHECKNUMBER I N T HE DESI GNATED COLUMN. A US T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA r T HI CS AND CAMPAI GNDI SCL OSURE BOARD .
CAUTI ON: Se c t i on 688 . 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 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 o rf o r a n y Comme 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 er t h an 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 .
DATE PAC I D NUMBER NAMEAND ADDRESS OF CONTRI BUTOR RELAT I ONSH I P AMOUNT J I F FCR
RECEI VED Of a p p l i c a b l e ) TO CANDI DATE RECEI VED RJND-( MMI DD/ YR ) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SER
NUMBERI NCOME
1 D# 7 5 ~ Z n k h7 ~ h l 4 ~ f P
CKIi 3 U3
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Fo r I n s t r u c t i o n s , Se e Back o r F or - -
COPLTRI BUTI CNS - MCNE' l TADCEY 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 TTEE RAME ( Mu s t b e s ame as o n S t a t eme n t o f O r g a n i z a t i o n )
MONETARYRECEI PTS
CHECK THI S BOX ! FAMENDI NG FORM
STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEVEDFROM A STATE PAC ( P OL I T I C A L A CT I ON COMMn TFE) , UST THE PAC I D EN T t S C A T I O NNUMBER AND THE PAC CHEi ( NUMBER I N TH E DESI GNATEDCOLUMN . A UST OF I D NUMBERS I S A V A I LABLEFROM THE I OWA ETHCS 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 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 s o rf o r an y Co mme r c i a l p u r p o s e b y 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 m m i t t e e s .
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT J I F FCF
RECEI VED Of a p p l i c a b l e ) TO CANDI DATE' RECEI VED R
( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e )
RAI SE
ERNUMBERWCONE
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Fo r I n s t r u c t i o n s , Se e Sa c k o f F o r
CONTRI BUTI ONS - MONEYTAKEN 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 TTEENAME ( Mu s t b e s ame a s o n S t a t e me n t o r O r g a n i z a t i o n )
l c ' ~ 7 U 5 '
o
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RECEi P r S
L I CHECKTHI S BOX I FAMENDI NG FORI A
STATE CANDI DATES NOTE I F A CONTRI BUTI ON I S RECE?V ED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMAMTTF- 9 , L I S T THE PAC I DENTI F I CAT I ONNUMBER AND THE PAC CHEKNUMBER I N TH E DESI GNATEDCOLUMN . A L I S T OF I D NUMBERS I S AVA I LABLE FROMTHE I OWA ETH I CS AND CAMPAI GNDI SCLOSURE BOARD.
CAUTI ON : Se c t i o n 68 B . 3 2 A ( 6 ) , I o wa Co de , 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 pi 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 o rf o r an y c omme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e e s .
DATE PAC I D NUMBER NAMEANDADDRESS OF CONTRI BUTOR RELAT I ONSH I P AMOUNT J I F FOF
RECEI VED Of a pp l i c a bl e ) TO CANDI DATE' RECEI VED
( MM/ DD/ YR) ANDPAC CHECK ( ( f a p p l i c a b l e )
FUNE
RAI SERNUMBER I NCOME
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Fo r l n s t r u c t f on s , See Back o f Fo r
CONTRI BUTI ONS - MONEYTAKEN 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 h i n d s )
COMMI TTEE' YAME ( Mu s t b e game as o n S t a t eme n t o f O r g a n i z a t i o n )
l C7GCS O
4 e Ag 2 71 1 5 SE/ ' t
I - - ~ k t 7 , ~
SCHEDULE
MONETARY( R e v . 0 6 1 9/7 ) RECc r PTS
L 7 CHECKTHI S BOX I FAMENDI NG F OR t i 1
STATE CANDI DATES ' V OT E; I F A CON TRI B UT I ON I S R E C E R '"VED FROM A STATEPAC ( P OU T I C AL A CT I ON COM 1A I T t ' E _ ) , L I S T THEPAC I D E N T I F I CA T I ONNUMBER AND THE PAC CHECK NUMBER I N TH E DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S A VA I L A B L - FROM THE I OWA E 7 1 - I 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 w a Code , p r o h i b i t s t h e u s e o f I n f o ml a d 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 s o rf o r a n y c o n v n e r c i a l p u r p o s e b y 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 e s .
DATE PAC I D NUMBER NAMEAND ADDRESS OF CONTRI BUTOR RELAT I ONSH I P AMOUNT q I F FOR
RECEI VED a t a p p l i c a b l e )
( MM/ DD/ YR) AND PACCHECK
. TO CANDI DATE'
( I f a p p l i c a b l e )
RECEI VED FUND-
NUMBERRAI SER
I NCOME
l ~ o , n 5 41 , c k k e ~ ' s $C I O# - ~ q a - E 7 t c . k , \ w q ` ~ S4
G7 ) KF& v c k - ~" J at , . S00; 7 3 / a o
I D#
/ a / L 1 1 o CK# . a~~/ , ~ 1 ~ 97 r ' l/ 3 ~ / r a y 2 c c , . S o o s l / s o
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Fo r I n s t r u c t i o n s , S e t = 8 ac i c o T Fo r
CONTRI BUTI ONS - MONEYTAKEN 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 TTEE i 4AME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i on )
l c ' ~ ! US o ~~~~
SCHEDULE
MONETARY
( Re v . 0 6 / 9 7 )
CHECKT HI S BOX t FAMENDI NG FORM
STATE CANDI DATES NOTE: I F A CONTR I BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACT I ON COMMI TTE- 9, L I S T THE PAC I DENT I F I CAT I ONNUMBER AND THE PAC CHECKNUMBER I N T HE DESI GNATED COLUMN. A L I S T OF I D NUMBERS I S AVAI LABLE FROMT HE I OWA ETHCS AND CAMPAI GNDI SCL OSURE BOARD .
CAUTI ON: Sec t i on 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 op i e d f r om r e p o r t s a n d s t a t emen 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 a n y c o mme 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 er t h an 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 .
DATE PAC I D NUMBER NAMEAND ADDRESS OF CONTRI BUTOR RELA T I O NSHI P AMOUNT J I F FCRRECEI VED Of a p p l i c a b l e ) TOCANDI DATE' RECEI VED
( MM/ DD/ YR ) AND PACCHECK ( ( f a p p l i c a b l e ) RAI SERNUMBER
I NCOME
I D#
~o r l l c r~D4 ~ l ~ 2 t $CK#
I D#-
CK#
/p(//v
. . ; ,as_ , z 2 _ Go ~ b r e a l~vl d, e. e ~- ~ t ~h . c ~ x o~ , S a l P t ! / ~a
q / a t I D# l or r a . L d ` t wt G Sr
CK#
y 1 1 ' t '~I v e c w emu D~~4g So
I D#- -Pr t o 14 r n R K L % _ x 1 _ Q
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A10CK#
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Fo r I n s t r u c t i o n s , - See Bac k o f Fo p,
C%NTRI BI I T I CNS - I MCNEY 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 TTEE MAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a ni z a t i o n)
~l C7US' o AA5rnmc~t r
SCHEDULE
AJ I MONE7ARY
( R ev . 0 6 1 9 7 )
REC2Pr S
CHECK T HI S BOX I FAMENDI NG FOR I W
STATE CANDI DATES NOTE: I F A CONTR I BUT I ON I S REC - VED FROMA STATEPAC ( P OL t t 1 C A L ACT I ON COMMr r r E ? ' ) , L I ST THE PAC I DENT I F I CATI ONNUMBER ANDTHE PAC CHECK NUMBER I N THE DESI GNATEDCOLUMN . A L I S TOF I D NUMBERS I S AVA I LABLEFROMTHE I OWA ETHI CS AND CAMPAI GNDI SCL OSURE BOARD.
CAUTI ON : Se c t i o n 6 8B . 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 pi 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 any c o mme r c i a l p u r p o s e b y a n y 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 .
DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR REL AT I ONSHI P AMOUNT d I F FCF
RECEI VED a t a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-
( MMI DD/ YR ) ANDPAC CHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOME
I D#l ~ eZ i n
R c s k '~
5 7
1 0 ~, z 33
l / < o y f c r T " ~c f ~4 r l ~, ,
CK#c ' ~, ~~« _ - SdbUL /
I D# , ~ ~ , r ' ~ r t iGCo
/ l / l DlCK#
CK#
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111- 7711 )
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F o r I r s t r u c t i c r s , Se e S a c k o r F ,
CONTRI L UTI CNS - - 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 TTEE NAME ( M u s t b e s ame a s o n S t a t e me n t & O r g a n i z a t i o n )
F, c J X5 0 ~ RA . S n , 4 k s s e , 0 ~ - , ,T
,) W.Rouse
N
SCHEDULE
MCNE : . A F Y( R e v . 0 6 / 9 7 ) R E C E F 7 S
CHECK T H I S S OX I FA ME N DI N G F O I 3
IN
I
S T A T E C AN D I D A T E S N O T E : I F A CO NT R I B U T I O N I S R E CE I V E D F R O M A S T A T E P A C ( P O L I T I C A L A C T 1 0 N C t 5 A A I T T E E ) , L I S T T H E P A C I D E N T I F I C A T I O NN U M B E R A ND T H E P A C C H E C K N U M B E R I N T H E D E S I G N AT E D C O L U M N . A L I S T O F I D N U M B E R S I S A V AI L A B L E F R C M T H E I O WA E T H I C S A N D C A MP A I G ND I S C L O SU R E B O A R D .
CAUTI ON : S e c t i o n 6 8 8 . 3 2 4 ( 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 s o r` c r a n y c omm e r c i a f 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 mmi t t e e s .
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR REL A T I ON S HI P AMOUNT J I F FC IRECEI VED ( i f a p p l i c a b l e ) TO CAND I DATE ' RECEI VED FUND-( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RA I S EF
NUMBER I N CO I V I E_ -I D# ~ / L I ( O YDm&- dWe r s ~ ] SS~C; a~ov o l ; ~ ~ l ~ I
CK# 1 3 q4Adi DN t l ~ oAr ~ t f I C > °
ONE'$ l b o .
-
" ~Ps l ' Y I D n l l S I . . L J t v k
I D #R ~ ` l 4 - ~ ~ - - h w- s l ~ I ~ Ss e . N J
9~aq D/ CK # 519 Duk S l r e e - i UNCl
/
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c K#. l 5 v 9 s W
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FOR I NSTRUCTI ONS, SEEBACKOF FORM
EXPENDITURES- - MONEYSPENT FROMCOMMI TTEE ACCOUNT
STATE PACCOMMI TTEES : NOTE : FOR CONTRI BUT I ONS MADE TO STATEWI DE OR LEGI S LAT I VECANDI DATES, L I ST THE CANDI DATE
I DENT I F I CATI ON NUMBER I N THE DESI GNATED COLUMNAND THEPACCHECK NUMBERFOR EACH EXPENDI TURE . A L I ST OF i D NUMBERS I S AVA I LABLE FROMTHE I OWAETHI CS & CAMPAI GN D I SCLOSURE SCARD.
COMMI TTEENAME ( Mu s t be s ame a s o n St a t e me n t o f Or g a ni z a t i o n)
SCHEDULE
MCNETARY I( Re v . 0 9 / 9 7 )
EXPENDI TURES
[ -1 CHECKTHI S 8 0 -Al FAMENDI NG FORM
- e s ; N ~ d Or ' ~ C , t l 4 G . k e r
( ~ Nyu l ~ f i r ,
p: . , e , u u ,
I
CANDI DATE
I D NUMBER( i f a p p l i c a b l e )
AND PAC
CHECKNUMBER
NAMEANDADDRESS TOWHOMEXPENDI TURE
( D i s b u r s e me n t ) WAS MADE
PURPOSE
( DESCRI BE TRANSACTI ON)
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FOR I NSTRUCTI ONS, SEE BACX uFFORM
EWXEENDI TURES - - MONEYSPENT FROMCOMMI TTEE ACCOUNT
STATE PAC COMMI TTEES: NOTE: FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLAT I VECANDI DATES, L I S T THE CANDI DATE I DENT I F I CATI ON NUMBER I N THE DESI GNATED COLUMN AND THE
PAC CHECK NUMBERFOREACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWAETHI CS & CAMPAI GN DI SCL OSURE BOARD.
COMMI T" TEE NAME ( Mu s t be s ame a s on St a t e me n t o f Or g an i z a t i o n)
> I P U S o f 4 a w, "SW. f o r TOwa f i i u s c
SCHEDULE
MONETARY I( Re v . 0 9 / 9 7 )
EXPENDI TURES
QCHECKTHI S B O^ ' 1 F
AMENDI NG FORM
CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED
EXPENDED ( 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/ DD / YR) AND PAC
CHECK
NUMBER
1 D# 1 3 2 1 o r / we e u ~ l i J q / ? F5 i t l C' Shds~~ . ~ l o oN .; f i t
~ l ~o~ CK#as i S . S t c ' f F ~ ~ c r }
SD$ DP~~~u ~ Z"vwk Sv b b oZ
I D#
CK#
I D# v
CK#
I D #
CK#
I D#
CK#
I D#
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FOR I NSTRUCTI ONS, SEE BACK OF F Oh r v 1
COMMI TT EE NAME ; M u s t b e same a s o n S t a t e m e n t o f O r g a n i z a t i o n )
F r ~ ; CNd s of R~. s AI i t 5 s cN - ~ , Pr T WA 1 , A t f s e
SCHEDUL E
I N K I ND
( Re v . 0 6 / S7 )
CONTRI BUTI ONS
( ] CHECK THI S BOX I F
ANI E : ND I NG FORM
DATE
RECEI VED
( MM/ DD / YR)
NAME AND ADDRESS
OF CONTRI BI J TOR
RELATI ONSHI PTO CANDI DATE
' ( i f a p p l i c a b l e )
DESCRI PT I ON
OF 1 N K I NDCONTRI BUTI ON
ESTI MATEDF AI R MARKET
VALUE
J I F F GR
FUND- RA I SERCONTRI BUT I ON
~ u pr e s s7 , 0 1 g , - , t Av e S . , C
T A~- e - e wJ e u c e zvwa
a F6 . 1 1~ r x p l -, - s s
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A t 11 uU I I k VV I wI VJ , J GL OMUA Ur PUKM
COMMI TT EE NAME( Mus t b o 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 )
i ' r i e i I J S o f Ra Sn I c ~ S . S e N ~r l o we r AD_se
NOTE T h i s s c h e d ul e r e p o r t s mone y l o a ne 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 t
TOTAL UNPAI D LOANS FROM LAST REPORTI NGPERI OD $ -
d -
PART 1 - MONET ARY LOANS RECE I VED JSREPORTI NGPERI OD( O r i g i n a l s o ur 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 s
i 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 . )
PODTOTAL ( 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 $ e t h e r e l a t i o n s h i p o f an y r e l a t i v e
ma k i n g ac 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 s h ow 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 ) an d a f f i n i t y ( r e l a t i v e s b y ma r r i a g e ) ( S e e Page 2 o f f o r m s
p 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 nd i d a t e , b u t t h e r e I s n o f a m l l l 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 umn whe n I t a p p l i e s
SCHEDULE f
I " LOANS
( Re v 0 8 / 9 6 )
RECE I VED& REP AI D
a CHECKT HI S BOX I FAMENDI NGFORM
PART 1 1 - MONET ARY LOAN REPAYMENT S MADE j f S REPORTI NGPERI 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 S c 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 REPAYMENT S ( PART l r )
F r o m S c h ed u l e E - TOTAL LOANS FORGI VEN
TOTAL OUTST ANDI NGLOANS END OF REPORT PERI OD
Pa g e
( f o r S c he d u l e F )
DATE
RECE I VED
MMI DD/ YR
NAME ANDADDRESS OF r ENDER
( I n c l u d e En d o r s e r s Name, I f A p p l i c a b l e )
RELATI ONSHI P
TO CANDI DATE
( I f r t y ~ w =.
AMOUNTOF LOAN
J i au , c l s s eu
8
R~ ~Ave . N. : e
~2~eacc e NCP f . ~DCVa
506
SDOD
DATE PA I D
( MMI DDI YR)
NAME AND ADDRESS OF LENDER
( I n c l u d e En d o r s e r s Name, I f A p p l i c a b l e )RELAT I ONSHI P
TO CANDI DATE'I f A l i c a b l e )
AMOUNT
REPAI D
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T HI S FORM I S USED BYCANDI DATES' COMMI TTEES ONLY
COMMI TT EE 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 )
~r ~cN~S ~ - ~ 1 ~ ~ 5 n ~ ~ s s ~ n 1 - ~r T~w~ I l o ~s c
PART I I - I T EMI ZED BREAKDOWN OF UNREI MBURSED EXPENSES P AI D BYCONSULTANT
TOOTHERS I N PERFORMI NG SERVI CES OF CONTRACT ( T h e se e x p en s es s h ou l d NOT b ePART - NAME AND ADDRESS OF CONSULTANT
r e p o r t e d o n Sc h ed ul e B , a s t h e y a r e d i r e c t p a yme n t f r o m t h e c o n s u l t a n t . )
Name o f Co n s u l t a n t
- T / ) C 1Y1 P 5 5" c , ) e
N ' ' n g Ad d r e s s
1 - 7 o 1 Lake
C i t y
S t a t e
Z i p Cod e
wa l ~ ~~ l t 7 0
~ To l v a
S~ 7v a
TOTAL ANT I CI PATED
CONTRACT
PERFORMANCERI
Mi D
COMPENSATI ON FOR
- T 5 M
T o \ Co l d - , - 6 ( 4
ESTI MATES OF PERFORMANCE
sSOD , Dv
U BREAKDOWN
OF MONETARY
( Re v 0 2 / 9 6 ) EXPENDI TURES
BYCONSULTANT
0CHECK T H I S BOX I F
AMENDI NG FORM
Pa g e
( f o r Sc h e d ul e G)
DATE . '
EXPENDED
MM/ DDI YRNAME AND ADDRESS TOWHOMEXPENDI TURE
( D i s b u r s e me n t ) WAS MADE PURPOSE
AMOUNT
EXPENDED
$
SUB- TOTAL
TOTAL ( I f l a s t p a g e o f t h i s s c h e du l e )