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Disclosure Summary Page DR-2: For Instructions, See Back of Form
Disclosure Summary Page DR-2: For Instructions, See Back of Form
15 0 g-
SIGNATURE OF PERSON FILING R DA E SIGNED
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I AM FILING A ' t CL REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR .
(report date) Indicate by #~
Check if this is final (termination) report and attach Notice of Dissolution Form DR-3 . County & Local Comdr ittees, enter County in
which Election is held
(You must continue to file reports until a DR-3 is filed .)
SUB-TOTAL .... . $
SUBTRACT TOTAL MONEY SPENT THIS PERIOD
Schedule B : Expenditures total (Attach Schedule B) (**also see debts and loans below) .. . .
Schedule F: Loan Repayments total (Attach Schedule F) ... .. ... . . .. .. .. .. .. .. .. .. .. ........ .. . . . .. .. .. .. .. .
CASH ON HAND at the end of this reporting period (if final report balance must
be zero) (Attach DR-3) . ........... .. .. .. . . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . . .. ........ .. .. .. .. .. .. .. .. .. . . . .. .. .... .. .. .. .. .. .. .. . $ Q,6Q /
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 68B .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 RELATIONSHIP AMOUNT 4 IF FOR
RECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-
(MM/DD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOME
ID# l n
r~
q1 loo CK#
5-0 .00
"u
5f n
F ~o~o
ID#
CK#
I D#
CK#
I D#
CK#
1D#
CK#
ID#
CK#
I D#
CK#
ID#
CK#
ID#
CK#
ID#
CK#
SUB-TOTAL
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
marriage) . If surname of contributor is the same as candidate, but there is no
familial relationship, enter "not applicable" in the relationship column .
Page ~- of - I
(for Schedule A)
FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
C:
COMMITTEE NAME (Must be same a tatement of Organization)
Ktj <
CANDIDATE \ NAME AND ADDRESS TO WHOM
Vyx 0 ' PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDED
EXPENDED (if applicable) (Disbursement) WAS MADE
(MM/DD/YR) AND PAC
CHECK
r
NUMBER
1D# bwn
Sam.
C K# ~~ ("}' S ~"
me.~ 'vo $
1D#
CK#
ID#
CK#
ID#
CK#
ID#
CK#
ID#
CK#
ID#
CK#
ID#
CK#
SUB-TOTAL $
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) .)
Page 1 of
(for Schedule B)
FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
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'Disclosure law requires candidates to disclose the relationship of any relative making an in kind contribution to the Page of
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives -~
(for Schedule E)
by marriage) . (See Page 2 of forms packet.) If surname of contributor is the same as candidate, but there is no
familial relationship, enter "not applicable" in the relationship column .
FOR INSTRUCTIONS, SEE BACK OF FORM
I
SCHEDULE
COMMITTEE NAME(Must be same as on Statement of ganization) F LOANS
, (Rev. 07103)
4-
RECEIVED
\ \A-i/- 1/ CL A.YC
& REPAID
f~TE : This schedule reports money loaned to t committee which is deposited in the committee El CHECK THIS BOX IF
JO n OJ AMENDING FORM
TOTAL UNPAID LOANS FROM LAST REPORTING PERIOD $ " V
PART I - MONETARY LOANS RECEIVED THIS REPORTING PERIOD PART II- MONETARY LOAN REPAYMENTS MADE THIS REPORTING PERIOD
(Original source of loan, such as a bank, must be shown if a third party is (Loans forgiven must be reported on Schedule E -- In-kind Contributions.)
. Include loans from carxiidate's personal - .)
involved
DATE NAME AND ADDRESS OF LENDER RELATIONSHIP AMOUNT DATE PAID NAME AND ADDRESS OF LENDER
RECEIVED RELATIONSHIP AMOUNT
(Include Endorser's Name, If Applicable) TO CANDIDATE OF LOAN (MM/DD/YR) (Include Endorsers Name, If Applicable) TO CANDIDATE' REPAID
MM/DD/YR IfA " ;cable'
$ If A ;cable
~'l2l+seat '~lur~a~ $
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