FOR INSTRUCTIONS, SEE BACK OF FORM FORM 17

17-
DISCLOSURE SUMMARY PAGE DR-2
(Rev . 07/2004)
I DISCLOSURE
REPORT
COMMITTEE NAME (Must be same as on Statement of Organization)
COMMITTEE FOR PASSAGE OF For Office Use Only
BELMOND - KI.EMME BOND REFERENDUM Comm . #
IMPORTANT: Indicate by # type of committee you are reporting for: Logged In
( 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 Political
Subdivision Candidate ( 8 )County PAC ( 9 )City PAC ( 10 )School Board or Other Political Subdivision PAC Computer
11 ) Local Ballot Issue Audited
CANDIDATE COMMITTEES ONLY :
Candidate Name Political Party (if applicable)

Office Sought District (if Senate or House)

Late reports are subject to possible civil and criminal penalties.

q,U44~
SIG URE OF PERSON FILING REPORT
L. UJkSt TELEPHONE
(640444-4269
DATE SIGNED
09-21-05

IAMFILINGA M ELECTION YEAR REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR .

(report date) Indicate by # 0
EICHECK IF AMENDMENT TO REPORT DATED Local Committees, enter Date of Election
SEPTEMBER 13, 2005
C] Check if this is final (termination) report and attach Notice of Dissolution Form DR-3. County & Local Committees, enter County in
(ou
Ymt uscoue ntintflrttil
o ie repos una DR3 -s iflie .) which Election is held
Wright, Hancock, 4 Fran klin

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
of the last reporting period or must be zero if this is first report filed.) ........ ..... ..... ............... ..... ..... $ 580 .51
ADD TOTAL MONEY TAKEN IN THIS PERIOD
Schedule A: Cash Contributions total (Attach Schedule A) (*also see in-kind below) .... .... . ......... 595 .00
Schedule F: Loans Received total (Attach Schedule F) ........ . .... . .... ........... ..... ................ .... . .... .....
Schedule H: Total Sales of Campaign Property (Attach Schedule H) ........ ..... ..... ........... .... ..........
(schedule H applies to Candidates' Committees Only)
SUB-TOTAL................ $ 1,175-51
SUBTRACT TOTAL MONEY SPENT THIS PERIOD
Schedule B: Expenditures total (Attach Schedule B) (**also see debts and loans below) .. . ......... 60 .40
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) . ..... .... ......... . .... . .... . . . . . . . .. . . ..... ...... ..... ..... .... . ............... ..... ..... ........... ...... ..... ... $ 1,115 .11
**UNPAID BILLS (From Schedule D - Attach Schedule D) .......... ..... ..... ........... .... . .... ..... ...... ..... ..... .... . ..... .... $ 384 .00
*IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedule E) ........ ..... .... . .......... . .... ..... ..... ..... ......... $
**OUTSTANDING LOANS (From Schedule F - Attach Schedule F) ............ ..... .... . ............... ..... ..... .... . ......... $
CONSULTANT BREAKDOWN (Schedule G Attached?) -YES - NO
CANDIDATE COMMITTEES ONLY :
VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H) $
STATE COMMITTEES : Submit a reconciled campaign account bank statement in January of each year.
For Instructions, See Back of Form SCHEDULE

CONTRIBUTIONS -- MONEY TAKEN IN

A MONETARY
(Rev . 07/03) RECEIPTS
(Including candidate's personal funds)
CHECK THIS BOX IF
COMMITTEE NAME (Must be same as on Statement of Organization) AMENDING FORM

COMMITTEE FOR PASSAGE OF BELMOND-KLEMME BOND REFERENDU

STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), USTTHE PAC IDENTIFICATION
NUMBER ANDTHE 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 otherthan 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 (f applicable) RAISER
NUMBER INCOME
ID#
KEVIN L. KETCHUM
08-30-05 207 6th Avenue NW $ 25-00
CK#
Behnond,IA 50421
ID#
TENOLD CHIROPRACTIC CLINIC
08-31-05 CK# 406 River Avenue North 100.00
Belmond IA 50421-1039
ID#

E:1
MARCIA J. BURT
09-01-05 CK# 2270 Victor Avenue 20 .00
Rg=- IA 50470-7520
ID#
TERRI M. HAVENS
09-01-05 CK# 1404 Bel City Lane 50 .00
Belmond. IA 50421
ID#
RODNEY A. MEINTS
09-02-05 CK# 2974 140th Street 400.00
Behnond.IA 50421
ID#

CK#

ID#

CK#

ID#

CK#

ID#

CK#

CK#

SUB-TOTAL

TOTAL (if 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
marriage) . If sumame of contributor is the same as candidate, but there is no Page 1 of 1
familial relationship, enter "not applicable" in the relationship column . (for Schedule A)
 FOR INSTRUCTIONS, SEE BACK OF FORM Rood,FMR SCHEDULE

EXPENDITURES -- MONEY SPENT FROM COMMITTEE ACCOUNT B

(Rev. 07/03)
MONETARY
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 & CAMPAIGN DISCLOSURE BOARD.

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

COMMITTEE FOR PASSAGE OF BELMOND-KLEMME BOND REFERENDUM
CANDIDATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNT
DATE ID NUMBER EXPENDITURE (DESCRIBE TRANSACTION) EXPENDED
EXPENDED (if applicable) (Disbursement) WAS MADE
(MMIDDNR) AND PAC
CHECK
NUMBER
ID#
UNITED STATES POSTAL SERVIC Postage Stamps
01-18-05 216 First Street NE 40 @$37 $ 14.80
CK#0034
Belmond, IA 50421
IQ#
BELMOND INDEPENDENT Local Advertising 04-21-05
05-20-05 CK#0035 215 East Main Street Meeting on 04-27 21,60
Belmond, IA 50421
ID# PRINTING SERVICES, INC. Advertising--Reminder 04-21-05
05-20-05 524 River Avenue North Meeting on 04-27 24,00
CK# 0036
Belmond, IA 50421
ID#

CK#

ID#

CK#

ID#

CK#

ID#

CK#

ID#

CK#

SUB-TOTAL $
TOTAL (Iflast page of this schedule) $ 60 .40

THIS BOX 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 personstentfies 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 persordentity on behalf of the candidate's committee. (Refer to
Schedule G instructions and Iowa Code 68A.402(3)(1).)

(for Schedule B)
 FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
D INCURRED
COMMITTEE NAME (Must be same as on Statement of Organization) (Rev . 08198)1 INDEBTEDNESS
COMMITTEE FOR PASSAGE OF BELMOND-KLEMME BOND REFERENDUM
CHECK THIS BOX
IF AMENDING
NOTE: Debts previously reported that remain unpaid must be included on this
Schedule, as well as any new obligations incurred in this period .
FORM

An 'incurred debt" is a debt for

DEBTSIOBLIGATIONS REMAINING THIS REPORTING PERIOD goods or services ordered or
(DO NOT INCLUDE LOANS -- SHOW LOANS ON SCHEDULE F) received, but not paid for by the
end of the reporting period .,
regardless of whether an invoice
has been received
DATE DESCRIPTION OF GOODS OR BALANCE OWED AT
INCURRED NAME AND ADDRESS OF PERSON SERVICES PROVIDED OR CLOSE OF
(MMIDDIYR) TO WHOM DEBT OR OBLIGATION IS OWED PURCHASED REPORTING
PERIOD'
$
PRINTING SERVICES, INC. Advertising : Reminder Issue
08-25-05 524 River Avenue North 08-25-05 192.00
Belmond, IA 50421 Special Election Sept. 13, 2005

[Same as above] Advertising: Reminder Issue

08-31-05 192.00
09-01-05
Vote Yes for the New School

SUB-TOTAL $

TOTAL DEBTS OWED BY COMMITTEE AT THE END OF THIS REPORTING PERIOD $

384.00

'If actual figure is unknown, show "estimated" beside the figure . Page 1 of 1
(for Schedule D)

CANDIDATE COMMITTEES NOTE :

'Incurred indebtedness also includes each person/entity with whom the candidate's committee has entered into a contract during the reporting period for future
or continuing performance. Enterthe name of the consultant who provides or procures services for items such as advertising, fund-raising, polling, managing, or
organizing services . Report on Schedule G the nature of performance and the estimated performance reasonably expected of the consultant.