FOR INSTRUCTIONS, SEE BACK OF FORM

CHECK ONE: FORM ATEMENT

J"This is an initial* Statement of Organization
DR-1 of
This is an amended* Statement of Organization (REV. 0712004) I ORGANIZATION

*An initial Statement of Organization must be Ned within 10 days of the committee's accepting contributions,
making expenditures, or incurring indebtedness exceeding s75a Amendments must be filed within 30 days of
a change. Penalties may be imposed forlate-filed Statements of Organization.

rA R~ for :5 'aPcox
COMMITTEE NAME 1 1 - -
0saoz ca~,~-, rr~--
IMPORTANT: Indicate type of committee you are reporting for.
(1 )StatewidelLegislativeMudge Standing for Retention Candidate (2 )Statewide PAC (3 )State Party (4 )County Central Committee
( 5 )County Candidate ($ )City Candidate (7 )School Board or Other Political Subdivision Candidate (8 )County PAC (9 )City PAC
10 )School Board or Other Political Subdivision PAC 11 Local Ballot Issue
COMMITTEE TREASURER (mandatory for all committees COMMITTEE CHAIR (mandatory t for a candidate's committee
Name 1 1
! - ,¢ 1;;
Name 1
l pf1lf ~I~OYV
Mailing Address l 1 l rS~ ~l,<Avef- Mailing Address 1 1 t- A"' ~,

C stir~r 1 zip Code 1 5 1 1 T 1

235 City, ate zip Code
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Phone
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tw G 2-~ s Phone ( )
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e-mail ~1'vt .ct..x `C4--S f~ lf~G7~-~ - l2!°t

e-mail -
INDICATE PURPOSE OF COMMITTEE - Check One Box Advocate for/against candidate(s) s
Comment or description :

Ty'
All Candidates Enter.
Office Sought WASAI/AlGTaA) GO tJA1 SkJ~d~ (ll~Cll~
~istrid:

Political Party (if applicable) 2&-W C ccx G ( Year Standing for Election : 2O
County/Local Candidates and Local BallotfFranchise Committees Enter:

~Y" w-si~l~ ~IVGT~ G~ J ~7~J Date of Election: l(1 D V Z-

T
Bank Account Nsnw 11 Candidate name 8 Address or Parent Entity tF 4Cs. if applicable).
1 l Affiliate. or Sponsor
7000 6- . FA d?4--
Nerne of Fi ncial InstiJutiardtype of Account 1 1 t Mailing Address 1 .l
i
Mailing Address -. 1-
t;. i S 1rU f i/ ~ JZ A
1 '1 City 1 1 State 1 1 Zip 1 1
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.11 l4 5 Z- 3 S~,
cny , 1 state 1 1 zip 1 1
Phone (3p`I) ~6 2 5
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e-mail ~m a-x -~ a-S 7R" Efl R'c 7`-c - /'tc

STATEMENTOF AFFIRMATION: By filing this document the committee affirms the following:

1. The committee and all persons connected with the committee understand that they are subject to the laws in Iowa Code
chapters 68Aand 688 and theadministrative
rules in Chapter 351 of the Iowa Administrative Code .
2. That lowe Code section 68A.402 and rule 351-4.9 require the filing of disclosure reports and that the failure to file these
reports on or before the required due dates
subjects the candidate or chairperson (in the case of committees other than a candidate's committee) to the automatic
assessment of acivil penalty and the possible
imposition of other criminal and civil sanctions.
3. That Iowa Code section 68A.405 and rules 351-4.38 through 4.43 require the placement of the words "paid for by'
and the name of the committee on all political
materials except fornoose items exempted by statute or rule. A committee filing this statement for purposes 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. That Iowa Code section 68A.503 and rules 351-4.44 through 4.52 prohlblt the receipt corporate
of contributions by all committees except forstatewide and local ballot
issue PACs .

5. Acandidate and a candideWs coawnittee may only expend campaign funds as permitted by Iowa code sections 68A.301 through 68A.303
and rule 351-4.25.
6. That the committee will continue to file disclosure reports until a8 activity has ceased, committee funds spent, debts resolved,
and a final report and a statementof
dincnhrfinn [DR-3S h+A hxwn fllnd.