-FXt INSTRUCTIONS, SEE BACK OF FORM

CHECK ONE : Reset Fotm FORM STATEMENT

F-. llis is an initial* Statement of Organization DR-1 OF
L_ This is an amended' Statement of Organization (REV. 05/2005) ORGANIZATION
An initial Statement of Organization must be filed within 10 days of the committee's accepting contributions,
making expenditures, or incurring indebtedness exceeding $750 . Amendments must be filed within 30 days of
a change . Penalties maybe imposed forlate-filed Statements of Organization. A candidate with an open
committee that exceeds $750 in activity foranother office shallfile within 10 days either a newor amended
DR-1 disclosing information concerning the campaign for the new office sought.

COMMITTEE NAME 1 1

<fc- VV\l(A, -c-iZf- L c.'r &n,rS A, R,ALG(k

IMPORTANT: Indicate type of committee you are reporting for.
(1 )StatewidelLegislatlve/Judge Standing forRetention Candidate ( 2 )Statewide PAC (3 )State Party (4 )County C4NtratCorWittee
(5 )County Candidate ( 6 )City Candidate (7 )School Board or Other Political Subdivision Candidate ( 8 )County PAC (-!)CttyPAib
(10 )School Board or OtherPolitical Subdivision PAC (11) Local Ballot Issue
COMMITTEE TREASURER (mandatory for all committees) COMMITTEE CHAIR (mandatory except for a candidate's committee)
Name mil_ 61 Name 1 1
., >nrvtrS ~L
Mailing Address II I ~~ Mailing Address 1 1
ZZO NGS
City, State 11 Zi- Code I I C,L ~ t City, State 1 1 Zip Code J. 1

Phone ( Phone ( )

e-Mail e-Mail
INDICATE PURPOSE OF COMMITTEE - Check One Box 2-Advocate for/against candidate(s) Advocate forlagai Mot issues)
Comment or description : ~(,q C-CLOU -T6 S t Uu4 Ct2'y , CLr\4 CatL)NC, L Cr O ,AW<S A 6q[G a
All Candidates ESVer. ~
Office Sought: 5L()1l1G Gl' ~tLN 1JUN(2.J 4-
District:

Political Party (ifapplicable) 0G P- (~- Year Standing for Election :

CountylLocal Candidates and Local BallotlFranchise Committees Enter.
of Election:
County: CU )ry' 1 Q C3
Ue::=id

Bank Account Name 11 Candidate name & Address or Parent Entity (PACs, if aonlicab)e).
1 1 Affillate. or Sponsor

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Name of Financial Institutionitype of Account 11 Mailing Address 1 1

A 1 ~-P, e1~ Sl. -~-

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Mailing Address, 1 1 City 1 1 State 1 1 Zip 1 1

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City 1 1 State1J. Zip J. 1 Phone o ('L-I -3 - 6odcn o
Sl UJ V GI'J
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( (~- e-Mail eTJk4l. w e

STATEMENT OF AFFIRMATION : By filing this document the committee affirmsthe following:

1 . The committee and all persons connected with the committee understand that they are subject to the laws in Iowa Code chapters 6aA and 68B and the administrative
rules in Chapter 351 of the lows Administrative Code.

2. That Iowa Code section 6aA.402 and rule 351-4.9 require thefiling of disclosure reports and that the failureto file these reports an or before the required duedates
subjects the candidate or chairperson (in the case of committees otherthan a candidate's committee) to the automaticassessment of a civil penalty and the possible
imposition of other criminal and civil sanctions.
3. That Iowa Code section 68A405 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 for those items exempted by statute or rule. A committee filing this statement forpurposes of using the shorter'paid forby' and who have not crossed
the $750 shall notify the Boardthat the $750 threshold will not be crossed.

4. That Iowa Code section 68A.503 and rules 351-4.44 through 4.52 prohibit the receipt of corporate contributions by all committees except forstatewide and local ballot
issue PACs.

5. A candidate and a candidate's committee 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 all activity has ceased, committee funds spell, debts resolved, and a final report anda statement of
dissolution (DR-afIlias been filed .

IL ~
Date signed

e Signed