Clinton County Republican Womens Club9521scanned

8/7/2019 Clinton County Republican Womens Club__9521__scanned

http://slidepdf.com/reader/full/clinton-county-republican-womens-club9521scanned 1/9

FOR I NSTRUCT I ONS, SEEBACK OF FORM

DI SCLOSURE SUMMARY PAGE

COMMI TTEE NAME ( Mu s t b e same a s o n St a t eme n t o f O r g a n i z a t i o n )

4 O °d ~̀̀GANUI DATE COMMI TTEES . : : ~ , r

OF PERSON F I L I NG REPORT

CHECK I F AMENDMENT TO REPORT DATED

PORTANT : I n d i c a t e b y # t y p e o f c , q mi t t e e Wo u a r e r e p o r t i n g f o) S t a t e w i d e / L e g i s l a t i v e / J u d g e S t a r f d i n g f o r R e t e n t i o n C a n d i d a t e ( ( 2 f a ~ t e PAC ( 3 ) S t a t e P a r t y

4 ) C o u n t y C e n t r a l C o mm i t t e e ( 5 ) C o u n t y C a n d i d a t e ( 6 ) C i t y C a n t f i d -a t e ( 7 ) S c h o o l B o a r d o r O t h e rP o l i t i c a l S u b d i v i s i o n C a n d i d a t e ( 8 ) C o u n t y PAC ( 9 ) C i t y PAC ( 1 0 ) S c h o o l B o a r d o r O t h e r P o l i t i c a lS u b d i v i s i o n PAC ( 1 1 ) L o c a l B a p a W-

Ca n d i d a t e Name I P o l i t i c a l P a r t y ( i f a p p l i c a b l e )

J AN 2 4 2 0 0 5O f f i c e S o u g h t D i s t r i c t ( i f Se n a t e o r H o u s e )

, ~1 a 3 - - ~ ~ 3 . - 1 1 9 3TELEPHONE

I AM F I L I N G A , ~~~ LAOREPORT FOR ( 1 ) ELECT I ON

( r e p o r t d a t e ) I n d i c a t e b y #

D Che c k i f t h i s i s f i n a l ( t e r m i n a t i o n ) r e p o r t a n d a t t a c h N o t i c e o f D i s s o l u t i o n F o r m DR- 3 .( Y o u mu st c o n t i n u e t o f i l e r e p o r t s u n t i l a DR- 3 i s f i l e d . )

STATEMENT OF CASH ON HAND

CASH ON HAND a t t h e b e g i n n i n g o f t h e r e p o r t i n g p e r i o d . ( T o t a l o f a l l f u n d s h e l d b y t h ec o mmi t t e e .

T h i s amou n tMUST

b e t h e same a s t h e c a s h o n h a n d a t t h e en do f t h e l a s t r e p o r t i n g p e r i o d o r mu s t b e z e r o i f t h i s i s f i r s t r e p o r t f i l e d . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

ADD TOTAL MONEY TAKEN I N T HI S PERI OD

Sc h e du l e A : Cash C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e du l e A ) ( * a l s o s ee i n - k i n d b e l o w ) . . . . . . . . .

Sc h e du l e F : L o a n s Re c ei v e d t o t a l ( A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . ,

Sc h e du l e H : T o t a l Sa l e s o f Camp a i g n P r o p e r t y ( A t t a c h Sc h e du l e H ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( Sc h ed u l e H a p p l i e s t o Ca n di d at e s' Commi t t e e s On I V )

SUB- TOTAL . . . . . . $

SUBTRACT TOTAL MONEY SPENT T HI S PERI OD

Sc h ed u l e B : E x p e n d i t u r e s t o t a l ( A t t a c h Sc h e du l e B ) ( * * a l s o s e e d e b t s a n d l o a n s b e l o w ) . . .

Sc h e du l e F : L o a n Re p a yme n t s t o t a l ( A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . , . . . . . . . . . .

CASH ON HAND a t t h e en d o f t h i s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t b a l a n c e mu st

b e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

* * UNPAI D BI L L S ( F r o m Sc h e du l e D - A t t a c h Sc h e du l e D ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . , . . . . . . . . . . . . . . . . $

* I N K I ND CONTRI BUTI ONS ( F r o m Sc h e du l e E - A t t a c h Sc h e du l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . $

* * OUTSTANDI NG LOANS ( F r o m Sc h e du l e F - A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . , . . . . . . . $

CANDI DATE COMMI TTEES ONLY :

CONSULTANT BREAKDOWN ( S c h e d u l e G A t t a c h e d ? )

VALUE OF CAMPAI GN PROPERTY ( F r o m Sc h e du l e H - A t t a c h Sc h e d u l e H ) $

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DATE S I GNED

NON - E LECT I ON YEAR .

L o c a l C o mm i t t e e s , e n t e r D a t e o f E l e c t i o n

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F o r I n s t r u c t i o n s , Se e B a c k o f F o r m

CONTRI BUTI ONS - - MONEY TAKEN I N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )

COMMI TTEE NAME ( Mu s t b e same a s o n St a t e me n t o f O r g a n i z a t i o n )

STATE CANDI DATES NOTNUMBER AND THE PAC CHE

DI SCLOSURE BOARD

F A CONTRI BUTI ON I S RECEI VED F ROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I D E N T I F I C A T I O NNUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GN

CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Cod e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c omme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

SUB- TOTAL

TOTAL ( i f l a s t page o f t h i s s c h ed u l e )

SCHEDULE

A MONETARY

( R e v . 0 7 1 0 3 ) RECEI PTS

0 CHECK THI S BOX I F

AMENDI NG FORM

* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h ec o mm i t t e e . R e l a t i o n s h i p mu s t b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b ym a r r i a g e ) I f s u r n a me o f c o n t r i b u t o r i s t h e same a s c a n d i d a t e , b u t t h e r e i s n of a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r Sc h e d u l e A )

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT I F FRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECEI VED F UND( MMI DDI YR) AND PAC CHECK ( i f a p p l i c a b l e ) RA I SE

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COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f r g a n i z a t i o n )

SCHEDULE

A MONETARY

( R e v . 0 7 / 0 3 ) RECEI PTS

0 CHECK T HI S BOX I F

AMENDI NG FORM

STATE CANDI DATES NOTE ! I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I D E NT I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETH I CS AND CAMPAI GN

DI SCLOSURE BOARD

CAUTI ON: S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c o mme r c i a l p u r p o s e b y a n y p er s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e es .

ov . . ~ o v , Z7 y ' Z SUB- TOTAL

TOTAL ( i f l a s t p a g e o f t h i s s c h ed u l e )

D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h ec o mm i t t e e . R e l a t i o n s h i p mu s t b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b yma r r i a g e ) I f s u r n a me o f c o n t r i b u t o r i s t h e s am e a s c a n d i d a t e , b u t t h e r e i s n o Page ' o ff a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r Sc h e d u l e A )

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELAT I ONSH I P AMOUNT q I F FRECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE ' RECE I VED FUND( MMI DD/ YR) AND PA C CHECK ( i f a p p l i c a b l e ) RAI SE

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CONTRI BUTI ONS - - MONEY TAKEN I N( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )

COMMI TTEE NAME ( Mu s t b e s ame a s 9 , p St a t e me n t o f Or g a n i z a t i o n)

SCHEDULE

A

( R e v . 0 7 1 0 3 )

MONETARY

RECEI PTS

7 7 1 CHECK T HI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : i F A C CD l G T RI B UT I C N I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I D E N T I F I C AT I O NNUMBERAND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA ETHI CS AND

CAMPAI GNDI SCLOSURE BOARD .

CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Cod e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c op i e d f r o m r e p o r t s a n d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c o mme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

SUB- TOTAL

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TOTAL ( i f l a s t p a g e o f t h i s s c h e du l e )

1$D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h e

m i t t e e . R e l a t i o n s h i p must b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b ya g e ) . I f s u r n a me o f c o n t r i b u t o r i s t h e s a m e a s c a n d i d a t e , b u t t h e r e i s n o P a g e-,~o f_

r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r Sc h e du l e A )

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSH I P AMOUNT d 1 F FORECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECEI VED FUND-( MMI DDI YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SE

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CHECK T HI S BOX I F

AMENDI NGFORM

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TOTAL ( i f l a s t p a g e o f t h i ss c h e du l e )

A MONETARY

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CANDI DATES NOTE : I F A 1 5 ' ONTRI BI J T * N I S RECEI VED FROMA STATE PAC ( POL I T ICAL ACTI ON COMMI TTEE) , L I S T THEPAC I DENT I F I CATI ON

AND THE P AC CHECKNUMBER I N THE DESI GNATED COLUMN. A L I S T OF I D NUMBERS I S AVA I LABLE FROM THE I OWA ETHI CS ANDCAMPAI GN

SCLOSURE BOARD.

AUTI ON : Se c t i o n 68B. 3 2 A ( 6 ) , I o wa Code . p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i e d f r o m r e p o r t s and s t a t e me n t s f o r s o l i c i t i n g c on t r i b u t i o ns o r

o r any c o mme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

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i s c l o s u r e l a w r e q u i r e s c a nd i d a t e c o mmi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h emi t t e e . R e l a t i o n s h i p mu s t b e s h o w n t o t h e t h i r d d e g r e e o f c o ns a ng u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b y

( Se e P a g e 2 o f f o r ms p a ck e t . ) . I f su r name o f c o n t r i b u t o r i s t h e s ame a s c a nd i d a t e . b u t t h er e i s n o P a g e o f

r e l a t i o n s h i p , e n t e r - n ot a pp l i c ab l e - i n t h e r e l a t i o n s h i p c o l u mn ( r Sc h e d u l e A)

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT J I F FOR

RECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-

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F o r I n s t r u c t i o n s , Se e Ba c . k o f F o r m

CONTRI BUTI ONS - - MONEY TAKEN I N( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )

SCHEDULE

( R e v . 0 7 1 0 3 )MONETARY

RECEI PTS

I ~ CHECK T HI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I F A &dN TRI BU T I ON I S RECEI VED FROMA STATE PAC ( POL I T I CAL ACT I ON COMMI TTEE) , L I S T THE PAC I DENT I F I CAT I ON

NUMBER ANDTHE PACCHECK

NUMBER I N THE DESI GNATED COLUMN.

A L I ST CF I D NUMBERSI SAVA I LAB LE FROMTHE I OWA ETH I CS ANDCAMPAI GNDI SCLOSURE BOARD.

CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c op i e d f r o m r e p o r t s a n d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c o mme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

TOTAL ( i f l a s t p a ge o f t h i s s c h e du l e )

l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h em i t t e e . R e l a t i o n s h i p mu s t b e s h own t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b yi a g e ) . I f s umame o f c o n t r i b u t o r i s t h e s a m e a s c a n d i d a t e , b u t t h e r e i s n o Pa g e - - 5 - o f

i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r Sc h ed u l e A )

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELAT I ONSH I P AMOUNT J I F FORECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECEI VED FUND-( MM/ DDI YR) AND PAC CHECK ( i f a p p l i c a b l e )

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MMI TTEE NAME ( Mu s t b e s ame o n St a t eme n t o f Or g a n i z t i o n )Z f~ ~ ,

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DI SCLOSURE BOARD.

SCHEDULE

( R e v . 0 7 ! 0 3 )

MONETARY

RECEI PTS

I ~ CHECK THI S BOX I F

AMENDI NG FORM

CAUTI ON : S e c t i o n 68 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i e d f r o m r e p o r t s a n d s t a t e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c ommer c i a l p u r p o s e b y a n y p er s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

SUB- TOTAL

TOTAL ( i f l a s t p a g e o f t h i s s c h ed u l e )

D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o m m i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h emi t t e e . R e l a t i o n s h i p mus t b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b y

i a g e ) . I f s u r n a me o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n o P a g e _ 6 o fi l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r S c h e d u l e A )

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT q I F FORECE I VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECEI VED F UND-( MMI DDI YR) AND PAC CHECK ( i f a p p l i c a b l e )

IRA I SER

NUMBER I NCOM

I D#h Ef ~ ~ ~ - '

3CK# 03 ~ j , 1 - z ~ ~ ~ - -~. ~ Z7 3 iCK#

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T HI S BOX APPL I ES TO CANDI DATES' COMMI TTEES ONLY :

Pu r c h a s e s o f c e r t a i n c a mp a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r mo r e mus t a l s o b e i n v e n t o r i e d o a Sc h e d u l e H . ( R e f e r t o Sc h e d u l e H i n s t r u c t i o n s . )

E x p e n d i t u r e s t o p e r s o n s / e n t i t i e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , o r g a n i z i n g s e r v i c e s mu s t a l s o b e d e t a i l i t e m i z e d o nc h e d u l e G b y t h e a mo u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e m a d e b y t h e p e r s o n / e n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o mmi t t e e . ( R e f e r t oc h e d u l e G i n s t r u c t i o n s a n d I o wa Co d e 6 8 A . 4 0 2 ( 3 ) ( i ) . )

( f n r Rr h ar l i i l a Rl

FOR I NSTRUCTI ONS, SEEBACK OF FORM SCHEDULE

EXPEND I TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT

( Re v . 0 7 / 0 3 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FOR CONTRI B UT I ONS MADE TO STATEWI DE OR LEGI SLATI VECANDI DATES, L I ST THE CANDI DATE I DENTI F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE El CHECK T HI S BOX I FPAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA AMENDI NG FORMETHI CS & CAMPAI GN D I SCLOSURE BOARD .

C94MI TTEE NAM ( M u s t b e s a m e a s o St a t e me n t o f O r g a n i z a t i o n )

CANDI DATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCR I BE TRANSACT I ON) EXPENDED

EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE

( I V I M / D D / Y R ) AND PAC

CHECK

NUMBER

1 D#

C K # / 2 , 5 0 $~~.

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SUB- TOTAL

TOTAL ( i f l a s t p a g e o f t h i s s c h e d u l e ) $



T HI S BOX APPL I ES TO CANDI DATES' COMMI TTEES ONLY:

Pu r c h a s e s o f c e r t a i n c a mp a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r mo r e mu s t a l s o b e i n v e n t o r i e d o a S c he d u l e H . ( R e f e r t o Sc h e d u l e H i n s t r u c t i o n s . )

E x p e n d i t u r e s t o p e r s o n s / e n t i t i e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , o r g a n i z i n g s e r v i c e s mu s t a l s o b e d e t a i l i t e m i z e d o nc h e d u l e G b y t h e a mo u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e m a d e b y t h e p e r s o n / e n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o mm i t t e e . ( R e f e r t oc h e d u l e G i n s t r u c t i o n s a n d I o wa C o d e 6 8 A . 4 0 2 ( 3 ) ( i ) . )

Pa g e . 2 - ;_

FOR I NSTRUCTI ONS, SEE BACK OF FORM SCHEDULE

EXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT

( Re v 0 7 / 0 3 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DEOR LEGI SLAT I VECANDI DATES, L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE CHECK T HI S BOX I FPAC CHECK NUMBER FOR EACH` EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD .

C l e r MI TTEE NAMr - 1 Mu s t b e s a m e a o n St a t e me n t o f O r g a n i z a t i o J

CANDI DATES DYAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE

( MMI DD/ YR) AND PAC

CHECK

NUMBER

1 D #

v

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SUB- TOTAL

TOTAL ( i f f a s t page o f t h i s s c h e d u l e ) $ 3 .7

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