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FOR INSTRUGTIONS,
SEE BACK OF FORM
CHECKONE:
$[fnts lsan tnltlal'statementof
Organizaton f-___-il
flfnis b an amended'stiatementoiorganizailon
' Sffi€monf must fu flled wthln 10 daysof ommtttee ataptlng onttbutlons, maldngexp@
l, K*?:.F9J:lLil
lnatrlng debfFexeedlng $750. Anendments mus' b filed wtthln30 daysof a change.
EffecdveJanuary 1,2010, all stabmente and reportsllled by nal commltoe for sGte ofrce must be filed
elecbonlcally and effdve January 1, 2012, all statementsand reporb ffled by all comndtteesbr siato ofrce *gg#
must be filed eleclronlcally.

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outold nameh ( ).
+ J (A candldate'scommltleemust lncludethe canttldats's tast name h the name ot the commftte.) lf
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ndPORTAt{T: lndlcab type of commltb you are rcpordng bn
I lStatewldefl-eglsldvelJudge Slandlng for Relendon Candldqte PAC(3lsble Pany
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5 )Counly Candl.lab ( 6 lGlty Candldate ( 7 )School Board or O{rEr PAC(e)cltyPAG:'- '-i

TREASURER (man&norv for

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STATE[!E![TOF Al.-mlM,llTlON: By f[ng thlB documentOrscommftreoffirms the iotlollrlng:

1. Theoornnltbs and all peFonscontEcledwlth the coimlttee undsEtardtrat t|ey a'o subjecfb tle ]ailE ln lowaCodEcfiapten SA ad 688 ard the admhffi\re
rubs h Chapterssl of fie louraAdmlnlsffiw Code.
2. Thst lowdCodeE€don 68A"/02and rule 351-4.9 requlrsthe fi0ngof dlscloslrereportgand thst th€ fanureb fflethesereporbon or bshrc the regulrrod
duedstes
s|.6jdthecandldale orctElrporson(ln the casecf commltteesdrarthanacandldate's commltl@)b theaubmaflca*sessnentda dvllpenaltyand f|€ posstUe
lmpclffon otothercrtnbEl anddvil sardorE
3. that lonraCodescfion ffiArl('s and rul€s351-4.38 through4./A r€gutothe placementdthe wontBFld tur ry andthe nanreotthe comr(dteoon all pofit@l
msterlals@ptforthceltemsexernptedbystatborruto. Acommlthetftdwhfiebreghileracommtthenameforpurposeduslngtheshorter"paldbrhf and
do6 nd lntendb crossthE$750ffllngtht€sholdshal ffle the FormDR-SFAformIn lleu of ffUngthb form.
4. Thatleya Codeeecdon@Afl13 and rulas3514.44 thtough4.52 ptohhnthe re@lptof cotpomtecotfiibr.donsby a[ commneesdcept ftr ballol hsue PACs.
5. A cadldoile anda cardldate'ocommltte mayonlyexpendcampa@fundsas perml[edby lowacodesec,tons&d301 throughSA"3fit andrule351-425,
6. Thetthe oomrdtbg wfllcontlnuoto f,lo dlscloglo rspofu unflla[ actvlty hasceased.oommltteofundsepent debb resolred,and a ffnalrepodand a #tement of
dlssoludon(DR-3)has beenfrled.