FPON : HRDt;f I NC . :~'BA1_ I HA I ESTPTES Dec .

30 2004 Q4 :33iirl P1

FOR INSTRUCTIONS, SEE B40IC Of FORM FORM STATEMENT

CHECK ONE ; I DR-1 OF
(Rev. ORGANIZATION
Z This is an initial' Statement of Orgarti6tion 2 9 2004
r- This is an amended` Statement of O~ran zationDEC 07/2003)
For Offl ;Ze Use Only
IS . ~r X
An Initial Statement of Organlzafionmust be 61gd withinfp sof 1 corrimi(tees accapllh~ oonHib-Noes, making Comm ax
expendflures, or incurring indebtedness exceeding $750. Amendments must be filed within 30 days of a change. Indexed
Ponafies may be imposed for late-filed Audited
Computer

COMMITTEE NAME :. J.
(~ i',i , N
1~:1 1~` 2 E I\ t~ A L., I '1 P-,4 S y Jb ! ( -e.e-
tl --~ _ n
IMPORTANT: Indicate type of commlttaa you are reporting for :
( 1 )StatewidelLeglttlatlva Candidate (2 )3tatewide PAC ( 3 )State Party (4 )County/Local Candidate ( 5 )County PAC ( 8 )Ballot IaaueIFranchi¢e
Committee (7 )Count rlgity Central Committee
COMM=E TREASURER (mandatory for all committees) COMMITTEE C R (mandatory except for a candidate's commtdeo)
Name.
Cl A c1C\ 1 n t' t/ 5 F-Y
-
Mailing Addre--qJ :. Mailin Ad r
?r Po~ .,t-
~.

31SyG tz Q 1
f\ t 101,

City, State I J. Zip Code 1 y City, State J1

ZipCe I J,

Phone ( 3-`X
1_~3 ~i . . ._Y Phone ( 3 ft y L) 3"10q ) --_
I
()-Mail e-Mai I
INDICATE PURP03E OF COMMITTEE - Check One Box Advocate forlagalnst candidate(s) U Advocate for against allot fssue(s)
Comment or descriAon:
All Candidates Erfr:
Once Sought: District:

Political Party (if applicable) _Year Standing for Election : 

CountylLocal Candidates and Local Sallot/Franchina Committees Enter.
County. Date of Election :
t3ank Account Name 1 1 Can id tA-"d ress or Parent ErKltY IPACS. t(appliWblel.
Ilats,_or Sponsor

Home of Financial Instltutionltype of Account 1 N r

Cc w,.uL-J ailing Address 1 .4

Mailing Address W City 1 J. State 1 Zip I 1

\ Ilk,
City ~. .l State 1 b Zip J. l Phone ( )  ,-

.r
0 ~<J~ trJ 1 G'1 `~ ~~~w~o ~ e-Mall _

filing this document the comratttse affirms the following:

STATEMENT OF AFFIRMATION: By

1 . The committee and r+h persona connerted with the committee understand that they are subject to the laws In Iowa Code chapters 88A and 88B and the
administrative rules in Chapter 351 of the Iowa Administrative Code.
2 . That Iowa Code section 68A .6 and rule 351-4.9 require the filing of disclosure reports and that the failure to flle thecs reports on or before the required due dates
sutxects the candidate or d,alrpereon (m the case of committees other than a candidate's committee) to the automatic assessment of a civil penalty and the possible
imposldon of other criminal and civil sanctions.
3 . That Iowa Code section 68A .14 end rules 351-d,38 through 4A3 require the placement of the words 'paid for Wand the name of the committee on all political
materials exrept for those Item exempted by statute or rule .
4 . That Iowa Code section 68A .15 and rules 351-4.44 through 4.52 prohibit the receipt of crxaoratecontrlbutions by all committees except for statewide and local
ballot issue PACs .
5. A candidate and a canddatas committee may only expend campaign funds as permitted by Iowa code sections SaA .40 through 68AA2 and rule 351-4 .25.
6 . That the corrrrrr~~)nnntttIIItree will continue to rile disclosure reports until all actlvtty has coased, committee funds spent debts resolved, and a final report and a statement of
dissolution (D has bean filed.
X'I -Z9-ate
Signature d Treasurer Date Signed
r --')~ 5; - 'n
3iflnaturenddate . OR "all other orxnmittom. Chairperson Signed