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FOR,NSTRUCTIONS,
SEEBACKOF FORM f;
DISCtOstif RErgtHlilltARV'pAGH.t 2889
BEc
28 ff & 59

rr\l .. ; '1r.':.rl
I A M F I L I N G A 12123/20O9': nEpbnrron til'eiicnon

p- Checkif this is final(termination)

reportand attachNotce of DissolutonFormDR-3.
(Youmustcontinueto file reportsuntila DR-3is filed.)
r:. "-1,;:.i.:.,

committee.This amountMUST,bethe sameas the cashon.handat the end - .,1 '

,. :4Q0.00
periodol mustbe zeroif thisi6 firstreportflled.)........................................:..
of thelastreporting $
ADD TOTALMONEYTAKEN]N THISPERIOD
Schedule total(AttachSchedule
A: CashContributions A) (.aisosee In-kindbelow)..............-.. 0:00

SUBTRACTTOTALIIIONEYSPENTTHISPERIOD
total'(AttachScheduleB) (-also see debtsand loansbelbw)..,.........'
ScheduleB: Expenditures
'.
4q0:po
ScheduleF: LoanRepaymenb total(At&ach
ScheduleF)..................,. :'0.00'
CASHON HANDat the end of this reportingperiod(if finalreportbalancemustbe zero).......................... 0.00
$
*UNPAIDBILLS(FromSchedule
D -AttachSchedule D)................... 0.00
.........$
'lN KINDCONTRIBUTIONS
(FromSchedule -Attrach
E Schedute E)..............,.... ...............S 0.00
*OUTSTANDING LOANS(FromScheduleF - AttachSchedute F).................... 0.00
..................
$
CONSULTANTBREAKDOWN(ScheduleG Attrached?) -YES / no
CANDIDATECOMMITTEES
ONLY:
VALUEOF CAMPAIGNPROPERTY(FromScheduteH - AttachScheduleH) 0.00
$
STATECOMMITTEES:Submita reconciledcampaignaccountbankstatementin Januaryof eachyear
 FOR"VSTRUCT'ONS,
SEEBACKOFFORM ll3WResetForm il SCHEDULE
I
EXPENDITURES - MONEY SPENT FROM COMMITTEE ACCOUNT B I raousranv
(Rev.07/03)| EXPENDTTURES
tI4IF_P49 COMMITTEES: NOTE:FORCONTRIBUTTONS MADETOSTATEWDE ORLEGISI-ATIVE
CANDIDATES,LlsrrHE cANDIDATE
PAccHEcKNUMBER
tDENTrFrcAnoN NUMBER tNrnLbeS'reiinrEDcoLUMNANDTHE
FoR EAcHExpENDtruRE.A Lrsr oF rDNUMBERs rs AvLrr_nsLeFRoMTHErowA
fl cnEcxrHrs
BoxrF
ETHICS & CAMPAIGNDISCLOSURE
BOARD. AMENDINGFORM

COMMfTTEE
NAME(Musfbe sameas on Sfafementof Organizationl
Lackore For School Board

EXPENDITURE (DESCRTBE
TRANSACTTON)
(DI sburseme nt) WAS MADE

Reimburse candidate for personal

1409 Prairie Ridge Drive funds spent on campaip yard signs
Polk city 1A50226 and flyers

TOTAL(lf last pageof thls schedule)

THISBOXAPPLIESTO CANDIDATES'COMMITTEES
ONLY:
Purchasesof certalncampalgnpropertycosting$500 or more must also be Inventorledon ScheduleH. (Referto ScheduleH Instrucilons.)

Expendlturesto personventiliesprovldlngconsulllng,advertising,fund-ralslng,polllng,managlng,organizingseMces must also be detail itemizedon

ScheduleG by the amount,purpose,and date ot each type of expendituremade by the person/entityonbehaf of the candldate'scommittee. (Referto
ScheduleG Instructionsand lowa Code
I
Page of

(for ScheduleB)