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?0l0llAR
FORINSTRUCTIONS
SEEBACKOF FORM
This Formto be filedfor eaci:

FL"ry filing.this.brm to usethe slrortel"paidfor bf atribution.The@mmifieewlllg! be oossingthe $7S0threshotd.*Thisbrm mustbe

filed pdorto the distribrrtonor peting of the politicalmsteriat.

E Amendedbrm updatingany previouslyfiled infonnationindudingDateof Eldion andYearStandingfor Eledion.

'lf 0p onmfra ctassesttp threshokl,
a DR-ISfrenpntd Organlzafun
must@ frledwilrtn10daysof the@mmifree's
aeqng @nttbunons,
matdng
exwrclfutes,arilrcuntnglrfubbdrcssexwdfigS750..
ln addltlon,
the@mmltbewillb requlrcdtofrbanpalgn di*loare rcpot6.

COltffllTTEE NAilIE + J (A candldab'scommitteemustlndudethe candldate'slastnsmeln ths nameof the commtfiee).

Betty Ellerhoff For Supervisor
IMPORTANT:lndlcatotypo ot commltteeyou arc regbilerlngfon I
(t f! Elatelflddl.ogl8latverJudgo Slandlngtor
FbtetdddLogloladyerJudgo Standlng for Relenfon
Retenton Csndldato
Csndtdato ( 2 ,Statswldo PAC ( 3lstab Pafi ( 4 )County Contral Conmlbe
-9ndldato ( 6 )clty canglgato( I )sclool Boardor othsr PortocalsubdMsloncandtd6 i e icountypAc ( o )clry pAc
( q)ggu-nty
( l0 )School
Boardor OtlrerPolldcalSubdlvlslonPAC( ll ) LocalBallotlssueflncludlnscommltbolnvoivedhhuHo6 citytdrruntv
COUIiITIEE CHAIR (mandatorylor all commltrteeeexcepta CAilDDATE (mandatoryercept for a non€ndldab commltbo)

MalllngAddress{ { MalllngAddrcss I J
652 cedar valley Rd 657CedEVa[ryRd
Clty,State J 0 Zp Code { J rip,^"a sznz Clty,State t I Zlp Code J J
riy'arA 52rr.
Et63'z66
Phone (ffi ) Phone (563 | E863266

INDICATEPURPOSE - Chck OneBox El edvocateturlagahstcandldate(s)

OFCOMMITTEE E Advocate br ballot lssue(B)
Commentor description: tr Advocate agalnst ballot lssue(s)
-'--'
All Gandldate Enten
c"*tYsqP*M Gounlyllocal Gandldabs and All OthsrcomnlttBea Enbn
ilrt*-S"tsht
countr Cedr
(f acfiveln multplebalot lssueelerflons,a[ach fst of courfiesor enlAr
"staiewide)
Daleof Electon. JmeE,20lO

gF AFFIRITIATION:By fttlng tnb documenttfte commttles afnrms the followtng:

STATEXUENT

1. The cotnnltFe€nd a[ pg|Eotlsconnectsdwi0r tho aommitbe mdemtand thd they are s.rblectb the lans in tom Code cha@rs 68A and 688 and tle adrddshativo
ruleoin Ghapter351 of the lswa AdminisffEtiveCode.
2. That lorvaGodeseciion6EA405 and ru16 gs1-{.39 ttilqrgh 4./l3 r€quiref€ pbcamentof the vtorb "paidfur bf and the mnle of $e commi&o on all poliscal
mabials eDce$ br thce ibms 6r@m@ by &tub or rule.
3. That lotvaCodeeection68A503 ard rulee351--4.rM through4.52 prohibitttn rcceiptof corpore confibrnioe by all conunitbesexcel br stabride ard l@l baltot
isglePAC$
4. That if the ommittEe reeds $7s) in campaigndivtty, a DR-1S&rnent d Organizationmustbe filed within I 0 days ard the committeeis requhredb fite campaign
disdaure reporb.
5. Tlrat$b fofln is ffled prior to f|e disbibudonor postingof politicalntatsriatrequfiingthe "Fid for ff atfiMion.
6. A rlw form or amerded brm b requiredb be filed br eadr qrbsegug|t electionthat I anr inwtved.

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, Pdaslsned