IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

VERIFIED STATEMENT
510 EAST 12 th , SUITE 1A REGISTRATION
DES MOINES, IA 50319 (Out-of-State Committees)
- www .iowa .gov/ethic s (Rev . 03/05)

VERWIED STATEMENT REGISTRATION For office use only

(Out-of-State Committee) Comm . #
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE .
Audited
SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .
Computer
THIS FORM MUST BE FILED FOR EACH C ONTRIBUTION IN EXCESS OF $50

COMMITTEE NAME
Offloial NaMe of Out-of-Slat~,,Committee .(Do not abgaviate Committe,~~ AVyIitten explanation must be provided for Acronym) .
Fire Fighters Interested m Kegistration an Q ~, ucatIon P KAY (-
Mailing Address
1750 New York Avenue
City, State, Zip Code Area Code & Telephone No .
Washington, DC 20006 (202) 737-8484

CONTACT PERSON FOR THE CO MMITTEE :

Vincent J. Bollon
N 0 New York Avenue Washington, DC 20006
Mailing Address it t io
(2 0
Email Address (Optional) Area Code & Telephone Number

Purpose of Committee/Contribution : (Please indicate by checking appropriate box)

Other PAC 1:1 Party (State or Central Committee)

Candidate 11 Ballot Issue PAC

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
IS REGISTERED OR OPERATES (Use separate page if needed to list more than one entity)

Name of Jurisdiction
State of Iowa International Association of Fire Fighters
Address
1750 New York AvenUO A ddress 1750 New York Avenues
elephone No . zip code
WasV." 665V006 (202) '/ .S /-c2S42S4 Washington, DC 29OSbate,

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Jack Reed Citizens to Elect Darren Bates
Mailing Address Mailing Address
PO Box 601, Council Bluff, fA 51502
427 Crestview Avenue
City, State, Zip Code Area Code & Telephone No . Date If In-Kind Contribution, Describe
Ottumwa, IA 52501 (515) 238-1414 10/25/2005
Amou t Committee . ID #
1,600.00 Ow A4
O~S~A 13482

VERIFIED STATEMENT OF COMMITTEE :

I Vincent J. Bollon , attest that the contribution reported above is accurate and that the information about this out-of-state
committee is correct and accurate to the best of my knowledge. 1 also attest that the reports filed in the named jurisdiction comply with requirements that are
substantially similar to Iowa Code section 68A402A6, including the disclosure of all contributions received and all expenditures made. 1 further attest that the
contribution re orted above was made from n account that does not accept contributions from corporations or other prohibited contributors under Iowa Code
section 68A. 3, unless the Iowa recipientm is a ballot issue committee. 1 understand that potential civil and criminal penalties may apply unless a copy
of this form as been filed with tt16)owa ics and ampaign Disclosure Board within 15 days of the date of the contribution .

/~.1
(Person submitti