05 :''19''1006 a7 :'21 1- 1'?-'?43-6660 CASS CO TREASURER PAGE i?

FOR INSTRUCTIONS, SEE BACK OF FORM FORM

DR-SFA Staternentof
VI am filing this form to use the shorter "paid for by" attribution . The committee will not be (Rev. 01/2006)
Organization
crossing the $750 threshold .' "Paid For By"

"if the committee crosses the threshold, an inltialOR-1 Statement o For office Use Only
of rite committee's accepting contributions, making expenditures, or Comm.#
addition, the committee will be required to flip campaign disclosure ri Indexed
Audited
Computer

CPMMITTEE NAME n rz (A candidate's committee must inclu

P- 1SUlSo
ORTANT : indicate type of committee you are registering for: 5
( I )Ststewide/Legisla6ve/Judge Standing for Retention Candidate (2 )Statewide PAC ( 3 )State Party (4 )County Central Committee
(5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Political Subdivision Candidate (9 )County PAC ( 9 )City PAC
( 10 )School Board or Other Political Subdivision PAC ( 11 ) Local Ballot Issue(Including committee involved in multiple city/county ballot issues)

COMMITTEE TREASURER (mandatory for all committees) CANDIDATE(COMMITTEE CHAIR (mandatory except for a candidate's
committee)
Name a a
~pN ypL~
Mailing Address a n
/ ~ ~ 020oSf=v~~-~
City, State a n Zip Code n x~ yC'

Phone (7)oZ) Phone Wi?- ) 2 6-/99--"

INDICATE PURPOSE OF COMMITTEE - Check One Box E rAdvocate for/against candidate(s) El Advocate for ballot Issue(s)
Comment or description : [1 Advocate against ballot iesue(c)

All Candidates Enter: / CountylLocal Candidates and Local Ballot Committees Enter:
Office Sought : C syPEk'U~Sz'ti' ,~
~~~ county : ~S S
Political Party (if applicable) ~l. C'Y r,) ! < i} (Ifactive in multiple ballot Issue elections, attach list of counties

Date_ of Election : 4~, - &

ST ATEMENT OF AFFIRMATION: By filing this documont the committee affirms the following :

1 The committee and all persons oenneded with the committee understand that they are subject to the laws in Iowa Code chapters E8A and 688 and the administrative
rulss in Chapter 351 of the Iowa Administrative Code .
2. That Iowa Code section 68A,405 and rvcs 351-4.38 through 4 .43 require the placement of the words "paid for by' and the name of the committee on all political
mntenals except for those items exempted by statute or rule .
3, That Iowa Code "dice 58A.503 and nrlos 351-4.4d through 4.52 prohibit1he receipt of corporate contributions by all committees except for statewide and local hallot
issue PAC :,

4, Thal If the cemlninee exceed!, $750 ~n campaign activity, a DR-1 Statement of Organization must be filed within 10 days and the committee is required to file campaign
disclosure reports .

iananl e o a , or till o ,er commi sea . roaraon il19-70