FOR INSTRUCTIONS, SEE BACK OF FORM

FORM I STATEMENT
CHECK ONE: DR-1 OF
0 This is an initial* Statement of Organization (Rev . 02/96) ORGANISATION
_
~1 1Z
$& This is an amended* Statement of Organization
For Office UseOnly ,
An initial Statement of Organization should be filed within 10 days of the committee's accepting
Comm . # 177
contributions, making expenditures or incurring indebtedness exceeding $500. Amendments should be filed
within 30 days of a change. Penalties may be imposed for late-filed Statements of Organization. Indexed
Audited
Computer

COMMITTEE NAME (Required by law)

t~y u y" M P'_0 r- &W, )_0 (r"'

IMPORTANT : Indicate type of committee you are reporting for.
(1 )StatewidelLegislative 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 committee)

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

Mailing Address Mailing Address

3r o 143 V-i-ee4 `'

City, State Zip Code City, State Zip Code ?
uNl~Eq v~taLE
k',4- 'amm&-,~e . L~ Sv 3 a.3
Home Phone (6 S) qg ?" 7 3 D` Home Phone ( )

Day Phone (5'15") 7- O/ Day Phone ( )

PACs : INDICATE PURPOSE OF COMMITTEE

All Candidates Enter: ~

l,"y U o ~Y
~
Office Sought : 01 ~~ d, i 1f9
. District : _ ' U a / Ios
Political Party (if applicable) d"46irl .jmarvw" Year Standing for Election : -4O®4
County/Local Candidates and Lo I BallotfFranc ise Committees Enter.
County: Date of Election : N0 J e rh 6- 07,
Bank Account Name Candidate Name & Address or Parent Entity (PACs, if applicable),
I Affiliate, or Sponsor

Il,VGII S Ij .r ,0 4~ ee_ 6t ee-kln e,~c lk"Y%kn^i '

Name of Financial Institution ype of Account Mailing Address

,VrR~ 1)ri vc 3 S 'T6 L !1 L/thttiQ.-

Mailing Address City State Zip

Got V-1 hcLir,, }-ow~x- Z.. .
jil d e 1 .A 5"000 3
City State Zip Home Phone

Day Phone (5IJ`~) e~ sb' ' e~

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 : n
(1) DONATED TO COUNTY CENTRAL COMMITTEE (6) PRORATED REFUND TO CONTRIBUTORS
(2) DONATED TO LOCAL/STATEfNATL 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) CITYICOUNTYISCHOOUSTATE 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
/am aware that Iam required to rile disclosure reports if the committee receives contributions, makes expenditures or incurs indebtedness in excess of five hundreddollars
in a calendar year forthepurpose of supporting or opposing anycandidate forpubfiC office or ballot issue. 1am also aware that late-filed reports are subject to civil penalties
(fines) under the disclosure law. /also understand that although the treasurer normally prepares and files reports, the candidate or chairperson (PACs) is responsible under the
timely disclosure reports. Finally, Iaffirm that allcommittee officers have been informed of theirappointment and obligations.

Date Signed

Date Signed