11/01/04 16 : 20 FAY 641 456 4776 HAMPTON STATE BANK 0002

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FOR INSTRUCTfONS, SEE BACK OF FORM FORM

DISCLOSURE SUMMARY PAGE DR-2 DISCLOSURE

(Rev . 07/2004) REPORT
COMMITTEE NAME (Must be same as on Statement of Organization)
For Office Use Only
YES? for H-D Students Comm . #
Logged In
IMPORTANT ; Indicate by # type of committee you are reporting for : 111 i
( 1 )Statewide/Legislative/Judge Standing for Retention Candidate ( 2 )State PAC ( 3 )State Party Scanned
( 4 )County Central Committee ( 5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other
Computer
Political Subdivision Candidate ( 6 )Cou nty PAC ( 9 )City PAC (10 )School Board or Other Political
Subdivision PAC (11 ) Local Ballot I ssy OA ; Audited

Late reports are subject to

possible civil and criminal
penalties .

Gyl - _lfL'- z5'S5' 0

TELEPHONE DAT S NED

First month after election

I AM FILING A REPORT FOR (1) ELECTION I(2)NON-ELECTION YEAR .
(report date) Indicate by #

Local Committees, enter Date of Election

OCHECK IF AMENDMENT TO REPORT DATED
10/5/04

El Check if this is Final (termination) report and attach Notice of Dissolution Form DR-3 . County & Local Committees, enter County in
which Election is held
(You must continue to file reports until a DR-3 is filed .) Franklin County

STATEMENT OF CASH ON HAND'

CASH ON HAND at the beginning of the reporting period . (Total of all funds held by the
committee . This amount MUST be the same as the cash on hand at the end
275 .81
of the last reporting period or must be zero if this is first report filed .) . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . $

ADD TOTAL MONEY TAKEN IN THIS PERIOD

Schedule A: Cash Contributions total (Attach Schedule A) (`also see in-kind below) . . . . . . . . . . 545 .00
Schedule F : Loans Received total (Attach Schedule F) . . . . . . . . . ., . . . . . . . . . . ., . . . . . . . . . . .  . . . . ., . . . . . . . . . . . . . 0 .00

Schedule H : Total Sales of Campaign Property (Attach Schedule H) . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . ., . . 0 .00

(Schedule H applies to Candidates' Committees Only)

SUB-TOTAL . . . . . $ 545 .00

SUBTRACT TOTAL MONEY SPENT THIS PERIOD
Schedule B : Expenditures total (Attach Schedule B) ("'also see debts and loans below) . . . . 503 .55
Schedule F: Loan Repayments total (Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 .00
CASH ON HAND at the end of this reporting period (if final report balance musi
317 .26
be zero) (Attach DR-3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

'"`UNPAID BILLS (From Schedule D-Attach Schedule D) . . . . . . . . . . . . . ., . . . . . . . . . ., . . . . . . . . . . . . . . ., . . . . . . . . ._ ., . . ., . . ., . . .$ 0 .00

'IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedule E) . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . .$ 0 .00
'*OUTSTANDING LOANS (From Schedule F - Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . ., ., . . . . . . . . . . . . . . . . . . . . . . ., . . $ 0.00
CANDIDATE COMMITTEES ONLY :
CONSULTANT BREAKDOWN (Schedule G Attached?) YES [:]NO
VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H)
11/01/04 16 :20 FAX 641 456 4776 HAMPTON STATE BANK Z003

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For Instructions, See Back of Form SCHEDULE
A MONETARY
CONTRIBUTIONS -- MONEY TAKEN IN (Rev . 07/03) RECEIPTS
(Including candidate's personal funds)

COMMITTEE NAME (Must be same as on Statement of Organization)

a CHECK THIS BOX IF
AMENDING FORM

YES! for H-D Students

STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMIT-TEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD .

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied fi-om reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT J IF FOR
RECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-
(MM/DD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOME
I D#
Verla Pecha
10/1/04 $25.00 ,
CK# Dumont, IA 50625

I D#
Teresa Peterson
10/1104 Dumont,1A 50625 $50 .00
CK#

I D#
Dan Johnson
10/1/04 Hampton, fA 50441 $50 .00
CK#

1D#
Craig Semler
10/4/04 CK# Hampton, to
50441 25 .00

I D#
Hampton Home Store
10/4/04 20.00
CK# Hampton, 1A 50441

I D#
Murphy Plumbing
10/4/04 Hampton, IA 50441 25 .00
CK#

ID#
Competitive Ag Services
10/4/04 Hampton, IA 50441 20 .00
CK#

ID#
Weldin Auto Body
10/4/04 Hampton, 1A 50441 25 .00
CK#

ID#
Kristi Wragge
10/6/04 CK# Hampton, 1A 50441 25 .00

ID#
Harry Birdsell
10/6/04 Hampton, IA 50441 25 .00
CK#

SUB-TOTAL 1 $ 290 .00

TOTAL (M last page of this schedule)

Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by 1 2
marriage) . If surname of contributor is the same as candidate, but there is no Page of
familial relationship, enter "not applicable" in the relationship column- F
_ forr Schedule A)
11/01/04 16 :20 FAX 641 456 4 776 HAMPTON STATE BANK 004

I
For Instructions, See Back of Form SCHEDULE
A MONETARY
CONTRIBUTIONS -- MONEY TAKEN IN (Rev . 07/03) RECEIPTS
(Including candidate's personal funds)
Q CHECKTHIS BOX IF
COMMITTEE NAME (Must be same as on Statement of Organization) AMENDING FORM

Yes! for H-D Students

STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL-ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD .

CAUTION : Section 66B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees.

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR i RELATIONSHIP AMOUNT 4 IF FOR
RECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-
(MMIDD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER _ INCOME
1D#
Steve Pearson
10/6/04 $20.00
CK# Hampton, IA 50441

ID#
Alan MoritZ
10/7/04 25 .00
CK# Hampton, IA 50441

ID#
Symet Seeds
10/12/04 CK# Hampton, IA 50441 25 .00

I D#
Leland Morrison
10/27/04 25 .00
CK# Hampton, IA 50441

ID# ,
LeAnn Strother
10/1/04 Hampton, IA 50441 20 .00
CK#

I D#
Hiclmran Chiropractic
10/1/04 Hampton, IA 50441 25,00
CK#

[D#
Craig Donn
10/1/04 Hampton, IA 50441 25 .00
CK#

ID#
Art Cady III
10/1/Q4 CK# Hampton, IA 50441 50 .00

ID#
City,
John Rowe
9/30/04 CK# Mason IA 30 .00

ID#
Bruce Harris
9/30/04 CK# Hampton, L4,50441 10 .00

SUB-TOTAL 255 .00

TOTAL (if last page of this schedule) $ 545 .00

Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by 2 2
marriage) . If surname of contributor is the same as candidate, but there is no Page of_
familial relationship, enter "not applicable' in the relationship column . (for Schedule A)
11/01/04 16 :21 FAX 641 456 4776 HAMPTON STATE BANK 2 005

FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE

EXPENDITURES -- MONEY SPENT FROM COMMITTEE ACCOUNT B MONETARY

(Rev . 07/03) EXPENDITURES

STATE PAC COMMITTEES : NOTE : FOR CONTRIBUTIONS MADE TO STATEWIDE OR LEGISLATIVE

CANDIDATES, LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE CHECK THIS BOX IF
PAC CHECK NUMBER FOR EACH EXPENDITURE. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORM
ETHICS 8 CAMPAIGN DISCLOSURE BOARD.

COMMITTEE NAME (Must be same as on Statement of Organization)

Yes! for H-D Students
CANDIDATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDED
EXPENDED (if applicable) (Disbursement) WAS MADE
(MMIDD/YR) AND PAC
CHECK
NUMBER
ID#
KLMJ Additional Radio Advertising
10/4/04 Hampton, IA 50441 $ 104.00
CK#

ID# Ron Raney Reimburse for stakes purchased at

10/11/04 CK# Hampton, IA 50441 Franlln County Lumber for yard signs 34 .86

ID#
Reminder Printing Advertising in Shopper
10/12/04 Hampton, 1A 50441 188.00
CK#

ID#
Hampton State Bank Reimburse for postage
10/18/04 Hampton, 1A 50441 23 .68
CK#

ID#
Hampton Publishing Printing ; of yard signs
10/18/04 Hampton, IA 50441 153.01
CK#

I D#

CK#

ID#

CK#

ID#

CK#

SUB-TOTAL $ 503.55
TOTAL- (if last page of this schedule) $ 503 .55

THIS SOX APPLIES TO CANDIDATES' COMMITTEES ONLY :

Purchases of certain campaign property costing $500 or more must also be inventoried on Schedule H. (Refer to Schedule H instructions .)

Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized on
Schedule G by the amount, purpose, and date of each type of expenditure made by the person/entity on behalf of the candidate's committee. (Refer to
Schedule G instructions and Iowa Code 68A.402(3)(i).)

(for Schedule B)