FORINSTRUCTIONS,

SEE BACK OF FORM

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I{l9lTAl.lT: Indlcategpe of commttee
( I )sbtewfd€rkglslaffve/Judge_shndlngfor ReGnuoncanauaollsauvtde pAC( 3 lsbte party ( 4 )County Cental Commttteo
( 9]Pu.nry_qndnde ( 6 )clty candldate( ? )schoolBoardor othir porrucat
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Name

citY'sabrr zPEBdo*"*,
A 52101
(563)91966]
Phone Phone15631382$Oq
o_Maillarrys@decorahbank.com
One Box I Advocatefor/againstcandidae(s;

county \Mnneshiek
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Septbmber14, 2010
Dateof Erecrion,

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Name of Financiallnstitrtiorutype of Account J J
DecorahBankand Trust Co
MailingAddress J J City J J StateJ I ap .1, J
202 E Water St
city J J StateJ I ap J J
Decorah,lA 52101

STATEMENT oF AFFIRMATIoN: By f,llng thls document the commlnee afrrms the iollowtng:

1.. Th€ qlmmitt€9-?nd-all persons conneded with the committes understand that thgy are subjeci to the laws in lowa Code chapters 68A and 688 and
the administratiw
rules in Chapter 351 of the lowa Adminisfative Cods.
2. That lowa Code section 684 .N2 and ruts 351--4.9 require tha filing of disclosure reports and that th€ failure to file thsse reports on or b€fore the
required duE datgs
subjects the candidate or chairperson (in the case of committees otherthan a candidatd's committee) to me automatic issessrnEnt of a civil ponalty
and'the possible
lmposition of othgr crimlnal and cMl sanctlons.
3- That loura Code section 68A.405 and rutes 351--4.38 throu€h 4.43 require the placement of the words 'paid for bts and the narne of
tho committee on a[ potitic€l
materials except for those items exempted by statute or rule. A @mmitt99 that wishes to regjster committbe nare ior purpo"o of using the
? shorter "paid for by" and
does not Intend to cross the g75o fiting threshold shall file ihe Form DR€FA fum in lieu of fiIing this form.
4. That lova Code section 68A503 and rules 351-:4.2t4 through4.52 prohibitlho receipt of corporateconlribufionsby alt committees
€xcept for ballot issus pACs.
5. A candidate and a candidate'scommitteo may only expend campaign funds as prmifted by towa cods seclions 68A.301 through 6g4303 and
rule 351--4.25.
6. That the commifteewill continueto fite disclosure reports until atl activity has ceased, committee funds spent, debts resolved,and a final report and.a
statement of
dissolutign (DR-3) has been filed.

-/b -zoto
4-7-Za/ O Date Signed