12/05/2005 (11 :04 FAX 7123668324

FOR INSTRUCTIONS, SEE BACK O

CHECK ONE : FORM STATEMENT

n This is an initial* Statement of Organization DR-1 OF

U This is an amended* Statement of Organization (REV . 05/2005) ORGANIZATION

An initial Statement of Organization must be filed within 7 fributions, For Office Use Only
making expenditures, or Incurring indebtedness exceeding e filed within 30 days of Comm, #
a change . Penalties may be imposed forlate-filed $totem n. A candidate with an open Indexed
committee that exceeds $750 in activity for anotheroffice sh within 10 days either a new or amended Audited
DR-f disclosing information concerning the campaign for the new office sought, Computer

COMMITTEE NAME .I, J, ~

t ~., ~ i~ ~` C1
IMPORTANT: Indicate type of committee you are reporting for. t I
(1 )Statewide/LegIslative/Judge Standing for Retention Candidate (2 )Statewide PAC (3 )State Party l~4)County Central Committee

( 5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Political Subdivision Candidate ( 8 )County PAC ( 9 )City PAC
f 10 )School Board or Other Political Subdivision PAC (- 1) Local Ballot issue
COMMITTEE TREASURER (mandatorv for committees COMMITTEE CHAIR (mendato axes for a candidate's commit*@
Name ~. 1

Mailing Address 1 1
22t 14^~,cC ~ ~"~~ Q
City, State b Zip,God e
_ __ c a-.-crt t --CA 5. S-l 3

Phone (?4 2} Z-~fo - Z c' `- )

NMI"
v

Advocate foriagainst candid e(s) U Advocate foriagainst ballot issue(s)

111111111W

District :

Year Standing for Election :

~z e,
Political Party (if applicable)
County/Local Candidates and Loca BallotIFranchise Committeft Fnter:
Date of Election:
County ?a c̀ -- W a '~-} ct` f~^L fG

Bank Account Name Candidate name 6 Address or Paront Entl (PACs If applicable)-
Affiliats, or S2ons9r

C
Name of Financial Institution/type o ccount ~ W Mailing Address

city Sta 1 71p 1

Mailing Address b

Z3 Jl)_ S +r e C, a l.. C-t

-17

City 1 1 State y J. Zip 1 J, , Z

Phone (ll2) Z5-'l6 .-' Z(

e-mail

STATEMENT OF AFFIRMATION: By filing this document the commm"" affirms the following :
Iowa Code chapters 68A and 88B and the adrnInIstraM
1 . The committee and all persons connected with the committee understand that they are subject to the laws in
rules in Chapter 351 of the Iowa Administrative Code,

2. That Iowa Code section 68A,a02 and rule 351-0 .8 require the filing of disclosure reports and that the failure to file these reports on or before the required due dates
civil penalty and the possible
subjects the candidate or chairperson (In the case of committees other then a candidate's committee) to the automatic assessment of a
imposition of othercriminal and civil sanctions,
the name of the committee on all political
3. That Iowa Code section 68A,4o5 and rules 351-4.38 through 4.43 require the placement of the words 'paid for by' and
shorter'pold for by"and who have not crossed
materials except for those Items exempted by statute or rule. A committee filing this statementfor purposes of using the
the 5750 shall notify the Board that the $750 threshold will not be crossed.
except for stalewlde and Local ballot
4 That Iowa Code section 68A,5o3 and rules 351-4 44 through 4,52 prohibit the receipt of corporate contributions by all committees
issue PACs .
code sections 66A.30i through 88A .303 and rule 351-4.25
5 A candidate and a candidste's committee may only expend campaign fundsas permitted by Iowa
debts resolved, and a final report and a statement of
e, That the committee wilt continue to file disclosure reports until all activity has ceased, committee funds spent,
dlssoltAivrrKS-3) has

r~f'-
Date Signed
LC-ZC ~ d~
Date Signed