FOR IigSTRUCTIONS, SEE BACK OF FORM

I
FORM STATEMENT
CHECK ONE: OCT 1 1 2001 DR-1 OF
ORGANIZATION
This is an initial* Statement of Organization (Rev . 07/00)

This is an amended* Statement of Organization For Office Use Only

An initial Statement of Organization should be filled within 10 days of the committee's accepting contributions, Comm . #
making expenditures or incurring indebtedness exceeding $500. Amendments should be filed within 30 days of a Indexed
change . Penalties may be imposed forlate-filed Statements of Organization_ Audited
Computer C

COMMITTEE NAME (Required by law)

~V1Wl rht t~ mil& t wack- e jt°_

IMPORTANT: Indicate type of committee you are reporting for: -

( 1 )Statewide/Legislative Candidate ( Z )Statewide PAC ( 3 )State Party ( 4 )County/Local Candidate ( 5 )County PAC ( 6)BaIIot~suelFranchise
Committee ( 7 )County/City Central Committee ( 8 )Support slate of candidates (list candidates unde r purpose of committe ey

COMMITTEE TREASURER This address used for all reminders and COMMITTEE CHAIR (List additional officers on separate page)
(Required by law) correspondence)

Name Name

r cti . t t-- i 5 ,
Mailing Address Mailing Address

_604 __W%±V! ch _ ________________________ _o&L t_D _R~~r~rn- fly-_____________________

City, State Zip Code City, State Zip Code

Phone (1515) J. Z~b -------------------

__________- __- ___-_ Phone (S17) =_`A '4-_5---------------------------
e-Mail ISGtG QhVY), -~3 ~jgJfYIC _LCf_V] -------------------- _--------------
INDICATE PURPOSE OF COMMITTEE - Check One Box Advocat o against candidate(s) a/ Advocate for/against ballot issue(s)
Comment or description :
All Candidates Enter:
Office Sought : _"lz----------------------------------------- District: _L&,AA<LLe_c-----------------

Political Party (if applicable) -AA----------------------------------- Year Standing for Election : lt11? ( __
County/~ca~l~~a~n~didates and Local Ballot/Franchise Committees Enter:
County: (~l-12--------------------------------------- Date of Election : _aj52 jo~

Bank Account Name 1 ~. Candidate name & Address or Parent Entity (PACs. if aoolicable) .
1 Affiliate, or Soonsor

Y] e_ JD_ ~I~~L_Y~ __ l_l __________ YY ' .I_ _-e ---------------------------------

Name of Financial Institution/type of Account ~. 1 Mailing Address

-----------------------------
Mailing Address J. City J. ~. State 1 J. Zip 1 .(

City ) .l State 1 .1 Zip Phone _____----------------

DISPOSITION OF BALANCE O FUNDS UPON DISSOLUTION (Statement of intent required by lawfor all committees, except state parties and central
Indicate disposition of funds by marking appropriate number in box committees and committees using only personal funds.)
(1) DONATED TO COUNTY CENTRAL COMMITTEE RORATED REFUND TO CONTRIBUTORS
(2) DONATED TO LOCAL/STATE/NAT'L POLITICAL PARTY (underline one) (7) TRANSFER TO ANOTHER COMMITTEE OF THIS SAME CANDIDATE

(3) DONATED TO CHARITABLE ORGANIZATION (CANDIDATES ONLY)

(specify) (8) RETURN TO PARENT ENTITY GENERAL FUND (PACs ONLY)

(4) CITY/COUNTY/SCHOOL/STATE OF IOWA GENERAL FUND (underline one) (9) OTHER (PACs ONLY), PLEASE BE SPECIFIC
(5) PARTISAN CONGRESSIONAL DISTRICT FUND

STATEMENT OF AFFIRMATION BY TREASURER AND CANDIDATE; OR POLITICAL COMMITTEES, BY CHAIRPERSON

I am aware that I am required to file disclosure reports if the committee receives contributions, makes expenditures, or incurs indebtedness in excess of
$500 .00 in a calendar year to expressly advocate for any candidate or ballot issue. I understand that although the treasurer normally prepares and files
e candidate or chairperson (PACs) is responsible under the law for accurate and timely disclosure reports and that late-filed reports are subject
il pe)talties and poAble gal action . I understand that by filing this form, I am subject to the laws found in Iowa Code chapter 56, chapter 68B
ministrative rulend in F ptQr 351 . I affirm that all committee officers have been inform d of their appointment and obligations.
U
Date Signed
s

rc f ate, O , C, CenyAl,Wittee or Local Ballot Issue, Chairperson