319-396-3380

Oct 10 05 10 :50a Alan Bernard

ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

VERIFIED STATEMENT
510 EAST 12th, SUITE 1A REGISTRATION
? I~~fJ DES MOINES, IA 50319 (Out-of-State Committees)
www.lowa.govleth)es (Rev, 0310S)

VERIFIM 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 CONTRIBUTION W EXCESS OF $50

COMMI TTEE NAME

Official Name of Out-of-State Committee (DO not abbreviate committee name . Written explanation must be provided for Acronym) .
le rPin~ Metricala .Promise
Mailing Address
607 14th Street, NW, Suite 800
City, State, <Ip Code -- Area Code -& Telephone No . ---
iiashington, DC 20005 (202) 654-1759

CONTACT PERSON FOR THE COMMITTEE :

Hattbew Butler
Name
607 14th Street, NW, Suite 800, Vashington, DC 200 05
Mailing Address City, State, Zip
(202) 654-1759
Email Address (Optional) Area Code 8 Telephone Number

Purpose of CommitteelContribution : (Please Indicate by checking appropriate box)

`-'Candidate 11 Ballot Issue PAC 11 Other PAC 0 Party (State or Central Committee)

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 Name

Federal Election Commission N/A
Mailing Address Mailing Address
999 E Street, NW
City, State, Zip Code Area Code & Telephone No, City, State, Zip Code
(202) Hashi rmton. DC 20463 4,24-9530

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name or Iowa Resident Name of Comm ittes
Shields for Cedar Rapids
Breast Wynja
Mailing Address Mailing Address
1.2 Burmiler Drive 3201 Pebble Drive, SW, Cedar Rapids, IA, 52404
City, Stale, Zip Code Area Code 8 Telephone No. Date If In-Kind Contribution, Describe
Amts, 1A 50010 (515) 283-7043 _ 10/6/2005
Am Committee. ID #
,%00 -00 13488

VERIFIED STATEMENT OF COMMITTEE:

1 Matthew Butler attest that the contribution reported above Is accurate and that The information about thus cut-of-state
committee is correct end accurate to the best of my knowledge. I also attest that the reports filed in the named jurisde6rxr comply with requirements that are
substangalfy similar to boa Code section 68A407A4 Inc*rdrng the disdosurs of all contribWrons received and all axpendltures made. I further attest that the
conirbuffon reported above made from unt that does not accept contnbutions from corporations or other prohibited contributors under low& Code
section 68A .50 I a rectpi millet is a ballot issue committee. I understand that potenliel cM/ and criminal pen
. .or may eppty unless a copy
of this f . s eh the to Ethics and Campaign Disdosure Board within 15 days of the date of the contrebcnior~ 00,
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