09, 28 :04 TL`E 13 :48 FAX 5157826658 WINDROW RESTAURANT&LOUNG z o01

FOR INSTRUCTIONS, SEE BACK OF FO ft

CHECK ONE: ' FORM STATEIV=NT
::Reset Form ,f.
This is an initial' Statement of Organization . OF
DR-1
[] This is an amended' Statement of Organization , (REV. 07/2004) ORGANIZATION
'AP 2 ,~L ~t For Office Use Only
An inifafT7q
Statement of Organizahen must be filed within 10 days of the committee's acavpfing contributions, Comm . # /
making expenditures. or incurring indebtedness exceeding$750. Amendments must be (led within 30 days of Indexed
a change. Penalties maybe imposed forlate-filed Statements of Organization. Audited _
Com uter

COMMITTEE NAME 11

C b~ ,W f~7 a
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IMPORTANT: Indicate type of committee you are reporting for

( 1 )StatewidefLegislative/Judge Standing for Retention Candidate (2 )Statewide PAC (3 )State Party (4 )County Central Committee
( 5 )County Candidate ( 6 )City Candidate (7 )School Board or Other Political Subdivision Candidate (8 )County PAC (9 )City PAC
L10 )School Board or Other Political Subdivision PAC ( 11 ) Local Ballot Issue
COMMITTEE TREASURER mandate for all committees COMMITTEE CHAIR mandate except for a candidate's committee
Name 11 Name , .
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a.
.- '+-1 1 1
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Mailing Address 1 1 Y maiiingAddress 1

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City, State 1 1 Zp Code 1 1
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city, sate 1
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Phone (w) 7 9 2 - `! lS 8 .3 Phone (g V/)

e-mail A/ 19 ` " e-mail ~/l

INDICATE PURPOSE OF COMMITTEE-Check One Bob (J itd to forragainst candidme(s) -1 Advocate forlagainst ballot issue(s)
Comment or description:
All Candidates Enter: '
Office Sought : N rY t O n if r.L ., r y .~ ~, iSG r District:

Political Party (if applicable) 1/~ ei 2 it ,R?hAe.a. 7- Year Standing for Election:
CountylLocal Candidates and Local Ballot/Franchise Committees Enter.
IA A ; Date of Election : 1.14 4' .-.~
County, 

Bank Account Name 1 1 Candidate name & Address or Parent Entity (PAC,, if apjilirable) .

lit, e l l 1 G. 7 JP S ty 1 AffiliateorSponsor

Gr .Sts Oar via cY

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Name of Financial Institutian/type o Account 1 1 Mailing Address 1 1
.2a 4s",w 4-~ e S k. C r .,S s
Mailing Address .~ 1 city 1 1 State 4. .6 zip y 1
4161 Lv /9G~G~~ S
Clly 1 y state 1 1 Zip y :, -
Phone -? `/ 4. - ~Q 1 S! c-
411)
C. I-eje,fGn
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e-mail

STATEMENT OF AFFIRMATION: By filing this document the committee affirms the following :

1. The committee and all persons connected with the committee understand the: they are subject to the laws in Iowa Code chapters BSA and 6613 and the administrative
rules in Chapter 351 of the lava Administrative Code_
2. That Iowa Code section 668.402 and rule 351-4.5 require the filing of d4ra0strtrbt 'repons and that the failure to rile these reports on or before the required C:c dates
subjects the candidate or chairperson (in the case of committees other than a candidate's committee) to the automatic assessment of a Gel penalty and the pC :;sible
imposition of other criminal and civil sanctions.
3 That Iowa Code section 688,405 and rules 351--4 . 3b through 4 43 require the placement of the words 'paid for by' and the name of the comminee on all po,incal
materials except for thoBe Item ., exempted by statute or rule, A committee filing This statement for purpose: of using the sooner 'pald for by and who have no : crossed
the 3750 snail nobly the So3rd that the 5750 1hreSndld u>JII not De crossed,
4. That Iowa Code section 0BA.503 and rules 351Jt,44 through 4.52 prohibit the receipt of corporate contributions by all committees except
for statewide arc Ideal ballot
issue PACs .
5. A candidate and a candidate's committee may only expend campaign funds as permitted Dy Iowa code sections 668,301 through 668,303 and rule 351--4 25 .
6. That the committee will continue to file disclosure reports until all ac iviry has ceased, committee funds spent, debts resolved . and a final report and a stalerent of
djssclulion (DR-3) has been riled . ,

Signature or rrcasutnr Date Signed

Signature of Candidate. OR, forau olncr , CnairpetT,on Dale Signed