FOR INSTRUCTIONS,

SEE BACK OF FORM FORM STATEMENT

CI1ECKONE:
.rz1tms is an Inltlaf"Statementof O rgan2afron DR.1 OF
(Rev. 10/2009) ORGANIZATION
E fnis is an amended*Statement oiOrganization Reset Fotm
For crflce Use Onlv
" slatement mustbe frled withln 10 daysof ammiftee a@pttng @nbibufions,maklng e
lncunlng debts excpr?dJnS Comm.#
9ZW. Amendmentsmug be filed wihin 30 daysoi a apige.
EfiecffveJanuary1,2010,all statements Indexed
andreportsfiledoy newcomm-ifteestoi sgib omcemustbeffted
andefiectveJanuary'1,2012,all statements
elechonically ind reponsfibd by all committees
for stat€oftce
Audlted
mustbefiledelectronicalty.

JJ(Acandldato,scommftteemust|nG|udethecand|date,8lastnamelnthenameJthecommfttee.)rm

IMPORI-ANT: Indlcate ffie of 6r6mtttee you are t6poiffig ion{

( I )ShtEnrldefleglsla0velJudge Standlng for Retenflon GandldaG de PAC ( 3 )Shto Party ( 4 )County Gentral Commlttee r r.1
( 5 )Gounty Candldate ( 6 )Ctty Candtdate ( ? )school Board or -t
Subdlvlslon Candldate ( I )County pAC ( 9 )Ctty pAq,! il

Phone(6gft!/o -/yJ(E

Advocate forlagainst candldate(s)

DareorElecnon, ^4 OIO
Y fVd

Clty + J Starel I Ztp J J

STATEMENT
oF AFFIRMAT|oN:By ffltng thle documontthe commltbs ffirmo tho followtng:

1'. Th€ commit€aand all personsconnectedwith the commitee understsndthat they aro subjoctto the laws In lowa Codechapters68A and 688 and the adminis,t'awe
rulosIn Chapter351 of the lornraAdministrafvoCode.
2. That lo$|aCodesedlon 68Arm2 and rute351-4.9 rcquircthe fillngd discto$re report8and thd the faltureto fite thesereporb on or berbretho requireddue dates
subJedsthe candldaleor chalrFrson (ln tho caseof commttteosotherthan a canditlatd'scommittee)to the automaflcass€ssrirentof a cMl penaltyand:thepossibte
lmpositionof othercrimlnalandcMl sanctlons.
3. That lowa Godesedlon @4.405 and rules351-4.38 throu€h4.43.rcqulrethe placementot the words'pald for bf and the nameof ihe commltteoon all poliucat
materlalsexc€ptfur thoseitemsexemptedby statuteor rule. A committeethat wlshesto regislera commltee nameior purposesof uslngthe shorter'paU t# Oy ana
doosnot intendto crossthE$750fillng threshotdshallfile the FormDR€FA form In lleu of fitlngthis form.
4. That fowaCodes6{ion 68A.503and rules351-4.44 tmough4.52 ptohlbftthe r@ipt of corporatecontibutionsby all @mmitbesox@ptbr ballotlesuspACs.
5. A candidate and a commfteemayonly e)Qendcampalgnfundsas permtttedby to\iyacodesecdons68A.A0Ithrough6&q.303and rule gS1-4.2S.
6. That the commltFs wlll to ffle dlsclosur€repor8 untl all acfivttyhas oeased,commntEefundssp€nt debtsresolved,and a ffnal reportand a statEmEntof
(DR-3)has
dlssolution