FORM lRev.

06/10)

Statementof Dissolution
EffectiveJanuary1,2010,thisform mustbe filedelectronically by
moststatecommittees. EffectiveJanuary1,2011,thisformmust
be filedelectronically
by mostlocalcommittees. Pleasecheck
withthe Boardto see if you are requiredto file it electronically.
Independent expenditure committeesmustfile thisform CertifiedDateof Dissolution H
electronically. ,,:
(-
P

t\t
s

Supporters
of PamJensenfor Treasurer
Officialhlameof Committee
e
1322llrh srreet

Street
Onawa,IA51040

City,State,Zip Code

(cell)
251-4645
(712 \
Area Telephone
Code

WHENTO FILE:
of Dissolution
TheStatement mustbe filedwithinthirty(30)daysof completion
of all thefollowing:
1. All debts,loansandobligations havebeenpaidor transferred;
2. All campaign fundshavebeenspent;
3. All campaignpropertysoldor transferred (candidates
only);and
4. A finalreportdisclosing
all transactions
closingthecommitteehasbeenfiled.

Forstatecandidates andstatePACs,a finalbankstatementmustbe filedwiththe Statementof Dissolution

or as soonas
possibleif the bankstatementis notavailableat thetimethe Statement
of Dissolution
is filed.

of Candidateor Treasurer(if candidate's

Signature of Chairor Treasurer(if PAC)
committee)/Signature

X /* 7* /a
DateSigned

SEE BACK OF FORM

FOR INSTRUCTIONS,

BoardAddress:510E 12t'StreetSte 1A,DesMoines.lA 50319 Fax Number:515-2814073