FOR INSTRUCTIONS, SEE BACK OF FORM FORM STATEMENT

DR-1 OF
CHECK ONE :
(Rev . 05/02) ORGANIZATION
This is an initial* Statement of Organization
[] This is an amended* Statement of Organization For Office Use Only

An initial Statement of Organization should be filled within 10 days of the committee's accepti
making expenditures or incurring indebtedness exceeding $750. Amendments should be filed
change . Penalties maybe imposed .for late-filed Statements of Organization .
er

COMMITTEE NAME (Required by law)

IMPORTANT : Indicate type of committee you are reporting for.

_ _ _ ,
_ . . rt slate of candidates flist candidates under purpose of committee)

COMMITTEE TREASURER This address used for all reminders and COMMITTEE CHAIR (List additional officers on separate page)
(Required by law) correspondence)

Name Name

1,.,x r rw r
Mailing Address
n'17
Mailing Address

2 y r.a. S. I-ILL, , ~' -

1Z 3 a, s, ; c~fr 9
City, State Zip Code City, State Zip Code

4,6617 ..x"2r:J XNW4150VV,Y Leo/7 J'__0 W61- SO

Phone ((ey/) ~y y Phone (lp~f~) yyi(D ' ~~

e-Mail e-Mail
INDICATE PURPOSE OF COMMITTEE - Check One Box Advocate for/against candidate(s) I" Advocate for/against ballot issue(s)
Comment or description: ` .;
All Candidates Enter ,
Office Sought : Lf /~ IP I/'J S,i!~ j" District: hl Aa
Political Party (if applicable) -IM U b 1l C Q. R Year Standing for Election : 2"00 6
15'(_27_"u r
County/Local Candidates and Local Ballot/Franchise Committees Enter:
County : Date of Election : Ne I~

Bank Account Name 1 .i. Candidate name & Address or Parent Entity (PACs . if applicable) .
Affiliate, or Sponsor

LalmrN L. tl-ST'r1
Name of Financial Instit ion/type of Account I ~. Mailing AI~

S.
Mailing Address .l- ~- City J. U~ te f. Zip
L eb "7 .~v wc~. 5d ly5'
f 'y~e
City I ~. State J. 1 Zip J. ~. Phone (tip yl ) '~'
' Y
e-Mail
DISPOSITION OF BALANCE OF FUNDS UPON DISSOLUTION (Statement of intent required by law for all committees, except state parties and central
Indicate dispositio n of funds bTmarkng appropriate number in box : 0 committees and committees using only personal funds.)
(1) DONATED TO COUNTY CENTRAL COMMITTEE (6) PRORATED REFUND TO CONTRIBUTORS
(2) DONATED TO LOCAUSTATE/NAT'L POLITICAL PARTY (underline one) (7) TRANSFER TO ANOTHER COMMITTEE OF THIS SAME CANDIDATE
(3) DONATED TO CHARITABLE ORGANIZATION (CANDIDATES ONLY)
(specify) - 11114 (8) RETURN TO PARENT ENTITY GENERAL FUND (PACS ONLY)
(4) CITY/COUNTY/SCOOUSTATE OF IOWA GENERAL FUND (underline one) (9) OTHER (PACs ONLY), PLEASE BE SPECIFIC
(5) PARTISAN CONGRESSIONAL DISTRICT FUND

TATEMENT OF AFFIRMATION BY TREASURER AND CANDIDATE ; OR POLITICAL COMMITTEES, BY CHAIRPERSON

I am aware that I am required to file disclosure reports if the committee receives contributions, makes expenditures, or incurs indebtedness in excess of
750.00 in a calendar year to expressly advocate for any candidate or ballot issue . I understand that although the treasurer normally prepares and files
ports, the candidate or chairperson (PACs) is responsible under the law for accurate and timely disclosure reports and that late-filed reports are subject
r civil penalties and possible other legal action . I understand that by filing this form, I am subject to the laws found in Iowa Code chapter 56, chapter 68B
ound in chapt r 351 . 1 affirm that all committee officers have been informed of their appointment and obligations.

1- ZI/-D&
SignaturRof Treasurer Date Signed
t
Signature o idate, OR, if PAC, Central Committee or Local Ballot Issue, Chairperson Date Signed