12 .''O .J% 2004 1 "J : 44 LAKESIDE (--ASINC ~ 15152813©1 tio .

822 D172

FOR INSTRUCTIONS, SEE BACK OF FORM

CHECK ONE : FORM STATEMENT

7 This is an initial' Statement of Organization DR-1

OF

0 This is an amended` Statement of Organization DEC - 3 2034 (REV O712COa) ORGANIZATION

For Office Use Only
l~~,c7
'An initial Statement of Organrza6on must be filed within 10 days of the Committees accepting contributions, Comm .lt
making expenalurat, or incurring indebtedness exceeding 8750 Amendments must be kited within 30 days of Indexed 
a change . Ponaltlbs may be imposed for late-tiled Statements of Organization, Audited
Computer

COMMITTEE NAME -b

4e,-- Z Dn ~_ trial ;:nl rvA ,®

IMPORTANT: I ndicato type of comm o you are re porting for-: 'T -
) 1 )Statewide/Legislative/Judge Standing for Retention Candidate ( 2 )Statewide PAC ( 3 )State Party ( d )County Central
Committee
)City PAC
( 5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Political Subdivision Candidate ( 8 )County PAC ( 9
1 10 SSchool Board or Other Political Subdivision PAC 1 11 1 Local Ballot Issue
COMMITTEE TREASURER (mandatory for all committees) _ COMMITTEE CHAIR (mandatory except for a candidate's comrnitteel
Name 1, 1. Name
~mr'YJOr~S
Ma fill Address 1 Mailing Address L ~
7 CrisrtyD Dr, " 'u e.
City, State ~l I Zip Code J, y City, State :. ~, Zip Code
(!2sce,rp L4 c-,> a) 3

Fhona i 61/rl31-.1 `CS- // Phone ( )

0,4K,AA J e-mail
e010 3il rt 5A,5 1A --
INDICATE PURPOSE OF COMMITTEE - Check One Box Advocate foriagsinst candidate(s) Advocate foriagainst ballot issue(s)
Comment or description .
All Candidates Enter:
Office Sought : District

Folifcal Party (it applicable) Year Standing for Election :

County[Local Candldatos and Local Ballot/Franchise Committees Enter
Date of Election :
County ~~I~LC.i~5~iy1ADtSUnI htlf}

jaank Account Name Candidate ame & Address or Parent Entity (PACs if applicable),
Affi y Gate
ate.. or Sponsof

Name of Flnsncial Institutionltype of Account 1 ., Mailing Address b J.

M2il,ng Address State Zip J.

City I 1 State ! ~ Zip 1 .1

Phone ( )

e-Mail

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

1 . Thin,committee and all persons connected with the committee understand that they are subject to the laws In Iowa Code chapters 68A and 688 and the administrative
rules in Chapter 351 of the Iowa Administrative Code .
dates
2 Thai Iowa Code soctlor 68A.402 and rule 351-4 9 require the fling of disclosure reports and that the failure to file these reports an or before Me required due
the poss,olo
subiects the candidate or chairperson (in the Case of committees other than a candidate's committee) to the automatic assessment of a civil penalty and
imposition of other criminal and civil sonctons .
committee on all political
3. That Iowa Code section 6&A.405 and rules 351--4,38 through 4.43 repulre the Dlacement of the words 'paid for by" and the name of the
materials except for those items exempted oy statute or rule, A committee filing this statement for purpocec of using the shorter 'Paid for by' and who have not crossed
the $750 shall notify the Board that the $750 threshold will not be crossed

4 Tliat Iowa Code section 68A.503 and rules 351-4 .44. through 4.52 prohibit the receipt of corporate contributions by all committees except for slaiawide and local ballot
issue PACs

5 A candidate and a candidate's committee may only expend campaign funds as permitted by Iowa code sections 68A.301 through 68A 303 and rule 351-4.25

G . That the committee wtl continuo to file ditc!osure reports until all activity has coosod, committee funds spent, debts resofvrad, and a final report and a statement of
dissolution (DR-3) has bean flea .

sgna'urc of Treseurer Date Slgred

Dste Slgnad