FOR INSTRUCTIONS, SEE BACK OF FORM FORM TEMENT

CHECK ONE: DR-1 OF

(Rev . 06'99) ORGANIZATION
7 - This is an initial* Statement of Organization
This is an amended* Statement of Organization

An initial Statement of Organization should be filled within 10 d s of the committee's acceg(y)j, rltnibutions,
making expenditures or incurring indebtedness exceeding $500 . ,~men e~,t : (t 30 days of
a change . Penalties may be imposed for late-filed Statements of f0ra~dA (

COMMITTEE NAME (Required by law)

---~ aj,ll .- s
K, r ~~z St-~ Pc R~~s

IMPORTANT : Indicate type of committee you are reporting for :

( 1 )Statewide/Legislative Candidate ( 2 )Statewide PAC ( 3 )State Party ( 4 )County/Local Candidate ( 5 )County PAC ( 6 )Ballot Issue/Franchise
Committee ( 7 )County/City Central Committee ( 8 )Support slate of candidates (list candidates under purpose of co mmitte e)

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

TepP- ~' i~ . ~t(J~~fS

Mailing Address Mailing Address

P,0, 4(;~c 30S P .D . `V»~ 3 ~s

City, State Zip Code City, State Zip Code

R106~ Rsl( 219 '5;ug r) Rt-,&2 Sc0c -)'- f+ 5V3~7

Home Phone (3 W `'( 10 $ Home Phone (311 ) (Q '19 5 0 7,I

Day Phone ( ,3l } `( 6 a Day Phone-(,--) I'( ~= Y S 0 7,

INDICATE PURPOSE OF COMMITTEE - Check One Box aAdvocate for/against candidate(s) ' Advocate for/against ballot issue(s)
Comment or description :
All Candidates Enter :
Office Sought: Lt' A 5 a-1, .~ c L am . C'_ e . 5 ~t Pc " r S o Rk District:

Political Party (if applicable) ~emaGV`a.'f' Year Standing for Election : oa

County/Local Candidates and Local BallottFranchise Committees Enter :
County : L-% A 514 / N G ?L ~t Date of Election: oU 5 oo

Bank Account Name ~- 1 Candidate Name & Address or Parent Entity (PACs, if applicable),
Affiliate, or Sponsor

1, 1k, F,, R 51 Pea u,5!, X, Trr AR Y (< . tr(i c, ?S

Name of Financial Institution/Type of Account Mailing Address

(J-+ A 5 Fl 1 N c i't, N 5i ti ° ~ ? 1 U, )3 ,j k 3 C1
Mailing Address City ~ 1 State ~- Zip 1
P. v . lzc'k 3 ( I Rt UzA5Cbd
City State S Zip Home Phone( ->>I ~) S va 8

` 735'7 Day Phone (3/1 20 V8

W -41 5di,6'2 A-
DISPOSITION OF BALANCE OF FUNDS UPON DISSOLUTION (Statement of intent required by law for all committees, except state parties and
central committees.)
Indicate disposition of funds by marking appropriate number in box:
(t) DONATED TO .,LIP~"haCl~ G COUNTY CENTRAL COMMITTEE (6) PRORATED REFUND TO CONTRIBUTORS
(2) DONATED TO LOCAUSTATEINATL POLITICAL PARTY(underfine one) (7) TRANSFER TO ANOTHER COMMITTEE OF THIS SAME CANDIDATE
(3) DONATED TO CHARITABLE ORGANIZATION (CANDIDATES ONLY)
(spay) (8) RETURN TO PARENT ENTITY GENERAL FUND (PACs ONLY)
(4) CITY/COUNTY/SCHOOUSTATE 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 . 1 understand that although the treasurer normally prepares and
files reports, the candidate or chairperson (PACs) is responsible under the law for accurate and timely disclosure reports and that late-filed reports are
subject to civil penalties and possible other legal action . I understand that by filing this fom-i, I am subject to the laws found in Iowa Code chapter 56,
and administrativeyuh<s fquno in chapter 351 . I affirm that all committee officers have been informed of their appointment and obligations .

I6
Signature of Treasurer Date Signed

Signature of Candidate, OR, if PAC, Central Committee or Local Ballot Issue, Chairperson Date Signed