nest. 3n nG OV : 03a CORY GRF i MRN 041-9?

3-4920 F-

FOR INSTRUCTIONS, SEE BACK OF FORM

CHECK ONE FORM STATEMENT

This is ar initial'Statement of Organzation D RA OF

This is an amended' Statement of Organization (Rev . 0112006) ORGANIZATIO~-1

'An initial Statement of Organization must be filed within 10 days o MuCennrAlft `S'attgphng r$ntnbutions, For Office Use Only
making expenditures, or incurring indebtedness exceeding $ 750 . Arnendrrterds mus-Y'behiktun 30 days of Comm . #
a change Penalties may be imposed for late-filed Statements of Organization A candidate with an open Indexed
committee that exceeds $750 in activity for another office shall hic within 10 days either a new or amended Audited
DR-1 disclosing infomnation concerning the campatgn for the new office sought. Computer -

COMMITTEE NAME 1 1 (A candidates committee must, include the candidate's last name in the name of the committee .)

IMPORTANT : Indicate type of committee you are reporting for

(_t)State%vide/Legislative/Judge Standing for Retention Candidate ( 2 )Statewide PAC( 3 )State Party (4 )County Central Committee
S ounty Candidate (6 )City Candidate ( 7 )School Board or Other Political Subdivision Candidate (8 )CountyPAC (9 )City PAC
0~)School Board or Other Political Subdivision PAC ( 11 )Local Ballot Issue(including committee-inv olved-in m ultiple city/county ballot issues)

COMMITTEE TREASURER (mandatory for all committees) COMMITTEE CHAIR (mandatory except for a candidate's committee)
Name 1 y Name

Mailing Address : ) ) Mailing Adres_ 1 1

City, State l 1 7_up Code 1 1 L h City, State - I Zip Code 1

Phone Phone ( )

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C"t --
INDICATE PURPOSE OF COMMITTEE - Check One F3ox Advocate forlagainstcandidate(s) Advocate for ballot issue(s)
Com m ent or desc.rl p6on 0 Advocate against ballot issuc(s)
All Candidates Enter- ~- . County[Local Candidates and Local Ballot Committees Enter:
~ - Cam_
'L
Office Sought
L"` t\ < <-~ c- _
County
Pol tical Party (i' applicable) _~ 7 ~ "~ (If active in multiple ballot issue elections, attach ist of counties

Dist n ft Date of Elecficnl / - (71

Year Standing for Election _
Bank Account Name Candidate name 8. Address- or Parent Entity (PACs, if applicable),
Affiliate, -jk s ! or Sponsor

Name of Firancial Inshtutionitype of Account 1 Mailing Address 1 L

Mailing Address 4 City 1 1 State 1 1 Zip 1 1

1 I State 1 1 zio Phone ((t' cl ) 3 - 3

e-Mail S ~0 y yL C' l. " ~i s Fd l1 C l1 , t

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

1 The ccr-nitlee and all persons conrected with the eommithee .+nrtea,!anrl that they are subject to the laws in Iowa Code chapters 68A and 688 and the admmisttative
rule-,in Ch .ipler 351 (if the low Administrative Code

2 . that lov..7 Code sect, on 68A .402 arid rule 351-4 .9 require the riling ~. ;I disclosuiu reports and that the failure to file these reports on or before the required due dal_ .

,
subjects 1110, ( :~ndldale nr chairperson (in the case of committees ether Than a candidate's committee) to the automatic assessment of a civil penalty and the posr,it-
imposi!ior of otFer nnriin l and civil sanctioris .

3 . That loviur CnJu m~ticni 68A .405 and rules 351-4 .38 through 4 .43 require the placement of the words "paid for by" and the narne of the committee on all poloir.a l
materials cxcupt for those items exempted by statute or rule . A corrunittee !hat wshus to register a committee name for purposes of using the suorter `paid for by' and
does not inland '.o crosz thn $750 filirq throsholc shall file the FOIm ORSFA hrrn! .

4 . That luv+a Cede sc(Aion 68A.503 and rules 351-4 .44 through 4,52 prohibitthe receipt of corporate contributions by all committees except for statewide and Icx:al l, :zllot
issue PACs

5 A r:andi,~ate and a candidate's committee may only expend ca-npaicr funds as permitted by Iowa code sections 68A 301 through 68A 303 and rule 351-4 .2= .

6 . That ttie tint-- will mntir ue to fite disclosure reports unlit aii ac!ivlty has ceased, committee funds spent, debts resolved, and a final report and a statement o'
dlsacrlur 3) I,asbeen file .

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