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lowa Ethicsand Campalgn

DlsclosureBoard
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Des Moines,lowa50319 FOR/NSTRUCZOruS,SEE8ACK OFFORM ,gf,
Fax: 515-281.4073
DISCLOSURE
nAM -6 Pr.?
J/|N
SUMMARYPAGE & 5,
COMMfTTEE
IfAME(Musfbe sdmoason Statementof
Organization)
INGERSLEV FOR HOSPITAL TRUSTEE

(Rev.07/2007)
;"f;t I o,,",_o,,".
standtng
! 1 Dtateyiqeilgsts!-ativerygdsg candtctite( z-)statepAc ( 3 )stateparry
for Rotentton | neeonr
(4)CounryCentral committee(5)qoqntycandidate (6)cttycaniio6ts tzfscdor'e-oaidorCjtherpotitcal
SubdivielonCandidate ( 8 )Counry pAC'(
eeC ( e )Ctty ro Fcnooieoardbr blhe'rFoniatSuUoivislon
iAd
11 ) LocalBallotlssue
CANDIDATECOMMITTEES ONLY:
Candidate Name
KIM INGERSLEV
ffice Souqht Dlstrict(if Senateor Houee)
HOSPITAL BOARD TRUSTEE

clvil and crlmlnalpenaltles.Pursuantto lowa CodessctionsOBB.32A(7)

and 6g4.401(3),the candidate,for a

'7tL-u?5-3853
TELEPHONE

IAM FILINGA JANUARYI9,2OO9 REPORTFOR(r) ELECTTON(2)NON-ELECT|ON

YEAR.
(reportdate) Indicare
by#U
ECHECK IFAMENDMENTTO REPORTDATED LocalCommittees,enter Dateot Election

p cnecr if this is final(termination)

reportanclattachNoticeof Dissolutlon
FormDR-3.
(Youmustcontinueto file reportsuntila DR-3is filed.) & LocalCommittees,
enterCountyin

STATEMENT
OF CASHON HAND
cAsH oN HANDat the beglnningof the reportingperiod.(Totalof ail tundsheldby the
committee.Thls amountMUSTbe the sameas the cashon handat the end
0.00
periodor mustbe zeroif thisis firstreportfiled.).....,......,..............................
of thelastreporting $
ADDTOTALMONEYTAKEN IN THISPERIOD
Schedule A: CashContributions total(AttachSchedule A) ("alsoseeIn-kindbelow).............,.... 0,00
Schedule F: LoansReceived total(AttachSchedule F).................... 0.00
Schedule
H: TotalSalesof Campaign
Property (AttachSchedule
H)...,............ 0.00
(ScheduleH aoollesto Candldates'CommltteesOnlvl
su 8.ToTAL................
0.00
$
SUBTRACTTOTALMONEYSPENTTHISPERIOD
Schedule total(AttachSchedule
B: Expenditures B) (*also seedebtsandloansbelow)............ 0,00
F:
Schedule LoanRepayments total(AttachScheduleF).........,,.,....,.. 0.00
cAsH oN IIANDat theendof thlsreporting
period(ifflnalreportbalancemustbe zero)..,..,,................... 0.00
$
0.00
'lN KINDCONTRIBUTIONS
(FromSchedule E - AttachSchedute
E)......,............. .............
S 0.00
*OUTSTANDING LOANS(FromSchedule F - AttachSchedute
R.................... .................
$ 0.00
CONSULTANT BREAKDOWN (Schedute
G Attached?) -YEs y' r.ro
CANDIDATE COMMITTEESONLY:
VALUEOF CAMPAIGNPROPERW(FromScheduteH - AttachScheduleH) 0,00
STATEGOMMITTEES:Submita reconciled
campaignaccountbankstatementin Januaryof eachyear.