QUAD-CITY FEDERATION OF LABOR, AFL-CIO

Serving Scott County Iowa and Rock Island County Illinois, and Vicinity
311V - 21st Street - Rock Island, Illinois 61201
21

January 20, 2005

Iowa Ethics & Campaign Disclosure Board

510 E 12th St # 1A
Des Moines, Ia 50319-9016

Dear Board :
Enclosed is a Verified Statement Registration form .
The check sent to the Committee to Elect Kas Kelly,
was never received by the candidate, and therefore
was voided and a new check has been issued January
20, 2005 .

If you have any questions please call me at my home,

309 788-9887 .

Thank You .

Sincerely,

Quad City Federation of Labor PAC #8020

01

Jackie McClintock, Treasurer

P .S . check #2277 dated October 12, 2004

 IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form
VERIFIED STATEMENT
514 EAST LOCUST, SUITE 104 REGISTRATION
DES MOINES, IA 50309-1912 (Out-of-State Committees)
(Rev . 1/00)
VERIFIED STATEMENT REGISTRATION For office use only
(Out-of-State Committee) Comm . #
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE.
SEND ORIGINAL-COPY TO THE BOARD AND Audited
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE. Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM.
Computer
COMMITTEE NAME
Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym.)
Quad City Federation of J.abor, PAC t 8090
1 Mailing Address
3.11 2-21st St .
City, State, Zip Code Area Code Telephone No.
Rock-Island, Il . 61201 ( 309), 7Ra-13n1

TREASURER OTHER OFFICERS (Attach second page if needed)

Name of Treasurer Name of Chairperson
Jackie McClintock -
Mailing Address v v ailing Address
311j-2 1st St
City, State, Zip Code Telephone City, Stale, Zip Code Telephone
Rock Island, Il 61201_ -(30991303 Rock Island, Ti- 61201 L3jp.0 22_i 3

IOWA RESIDENT AGENT

PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
ig~ 0 9fFies ident Agent (Use separate page if needed to list more than one entity)
Tyge,d Name ofwa Resident Name
r~ . 0EF Quad City Federation o£ La bor, AFL-CIO
Mailing Address Mailing Address
St
City, State, Zip Code Telephone ~7j City, State, Zip Code
Rock Island, 11 61 203

PURPOSE OF COMMITTEE:
Support candidates endorsed by the AFL-CIO

IOWA COMMITTEE RECEIVING CONTRIBUTION

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE
IS REGISTERED OR OPERATES Name of Committee
Cnmm a Elor-t Kas Ke~~~'
Name of Jurisdiction Mailing Address
State Board of Elections 1549 Washington, Muscatine, Ia
Mailing Address Date If In Kind Contribution, Describe
.0 . Box 4187 1-20_ns
City, State, Zip Code Telephone 4141 Amount
I _jnrincfipld R T1 62708 _0_12_1_2Z2_-_ $200 .00

VERIFIED STATEMENT OF COMMITTEE:

I swear that the contribution reported above is accurate. I further swear that the information about this out-of-
state committee is correct an accurate to the best of my knowledge. I attestall that the reports filed in the namedjurisdiction comply with requirements which are
substantially similar to Iowa Code section 56.6, including the disclosure of contributions received and all expenditures made. I further attest that the contribution
reported above was made from an account, which does not accept contributions from corporations or other prohibited contributors under Iowa Code section 56.15.
I understand that Iowa committees are prohibited from accepting contributions from out-of-state committees unless a signed original of this form has been filed with
theme Ethics and Campaign Disclosure Board, or the out-of-state committee is registered and filing full disclosure reports In Iowa .

4bnly Signature of Treasureror Chairperson)

Subscribed and swom before me this 20th day of January

My notary commission expires

"OFFIC'
Susann;a Sandberg
Notary Pub;;,:, St atu of IIlinois
My Cgmtnicsk?n Ftp. 07/29/2007