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FOR I NSTRUCTI ONS, SEE BACK OF FORMDI SCLOSURE SUMMARY PAGECOMI YMTTE E NAME ( Ws t be s ame a s o n St a t e me n t o f O r g e n i e t i o n )

S~ ~ , IHI PORTAMd I n d r a t e - by # t y p e o f c o r r r v i l l e e y ouwer e po r n g f o r :: - -( 1 ) S t a l e w i d e n e g i s l s t i v e / J u d g e St an d i M f o r R e t e n t i o n C a n d i d a l a ( 2 ) S t a t e PAC ( 3 ) S t a t e P a r t y( 4 ) Co u r k y C e r t r a a i C o r r r r ~ I L e e ( S ) Co mi t y C a n d i d a t e ( 6 ) C i t y Can di d at e ( 7 ) Sc h o o l Bo 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 Ca n d k i d e ( S ) C o u n t y PAC ( S) Ci t y PAC ( 1 D) Sc h o o l Bo a r d o r Ou t e r P o 6 c a lS u b d i v i s i o n PAC ( 1 1 ) L o c a l B a l l o t I s s u eCANDI DATE COMMI TTEES ONLY :Ca n d i d a t e Na v l c s 4

I G T F PEROO1 1 F I L E PO TELEPHONEl

I AMF I L I NG a 0~: X ' 7 0 6( r e p o r t d a t e )

L I CI 4 E CK I F AMENDMENT TO REPORT DATEDCheck 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 an d a t t a c h o f Dial F&mDR=3 . Co u n t y & L o c a l C o n v n i t t e e s , e n t e r Co u n t y i n

( Yo u mu s t 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 l e d . ) wh i c h ; E l e c t i o n i s h e l d

SUBTRACT TOTAL MONEY SPENT THI S PERI OD

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P c a l P j i f a p p l i c a b l e )d CV4 i 0 4 , r , ;D i s t r i c t ( i f Se n a t e o r Ho u s e )

ORT FOR ( 1 ) ELE O~ I ct r i d w a t e b y 0

I K 0 4 t o " ACo r mi f t e es , e n t e r D a t e o f E l e c t i o n

STATEMENT OF CASH ONHANDCASHON HAND a t t h e b eg i mi 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 i i d s h e l d by t h e

c o mmi t t ee . T h i s am o u n t MUST be t h e same as 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 be z e r o i f t h i s i s f a s t r e p o r t f i l e d . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ADD TOTAL MONEY TAKEN I N THI S PERI ODSc h ed u 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 ed u l e A ) ( * a l s o s ee i n - k i n d b el o w) . . . . . . . . .Sc h ed u 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 ed u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h ed u l e H : T o t a l Sa l e s o f Camp a i g n Pr o p e r t y ( A t t a c h Sc h ed u l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 Sc h ed u l e H a p l l e s t o Ca t ~ l d a t e s ' Co mmi t t e e s OnI ASUBTOTAL . . . . . $

Sc h ed u l e F : L o a n Re p a y me n t s t o t a l ( A t t a c h Sc h ed u 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 t f i n a l r e p o r t b al a n ce mu s t

be z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $" UNPAI DBI L L S ( F r o m Sc hed u l e D - At t ac h Sc h ed u l e D) . _ . . . . . . . . . . . . _ . . . . . . . _ . . _ . . . . . . . _ . _ _ . . . . . . . _ _ . . . . . . . . . _ . . . . . . . _ . $" I N K I ND CONTRI BUTI ONS ( F r o m Sc h ed u l e E - A t t a c h Sc h ed u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $" OUTSTANDI NG LOANS ( F r o m Sc hed u l e F - A t t a c h Sc h ed u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $CANDI DATE COMMI TTEES ONLY :CONSULTANT BREAKDOWN ( Sc he du l e G At t a ch ed ? )VALUE OF CAMPAI GN PROPERTY ( F r o m Sc h ed u l e H - A t t a c h Sc h ed u l e H)

FORMDR- Z DI SCLOSURE( Re v _ 0 7 1 2 0 0 4 ) REPORT

L a t e r e p o r t s a r e s u b j e c t t op o s s i b l e c i v i l a n d c r i mi n a lp e n a l t i e s

C e T o & v ' Z 6 . z aDATE SI GNEDLECTI ON YEAR.

Sc h ed u l e B : Ex p en d i t u r e s t o t a l ( A t t a c h Sc h ed u l e B) ( ` * a l s o s ee d ebt s a n d bans b el o w) . . . .

YES

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Fo r I n s t r u c t i o n s , Se e Ba c k o f F o r mCONTRI 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 ( M l r r s t b e s a f n el s o n S t a t e y n e n t o f Or g e ni z e k o n)

K e s e t } ' o r t n

STATE CAND I DAI MS NOTE : I F A CONTRI BUTI ON I S RECE I VED FROM A STATE PAC ( P OL I T I C A L ACTI ON C OM M I T T E E ) , L I S T THE PAC I D EN T I F I C A T I O NNUMBER ANDTHE PAC CHECK NUMBER I N THE DESI GNATED COLU MN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA E T HI C S AND CAMPAI GNDI SCLOSURE BOARD .CAU T I O N : S e c t i o n 6 8 8 . 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 an d s t a t e m e 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 commer c i a l p u r p o s e b y a ny 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 ommi t t e es .

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 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 n d i d a t e , b u t t h e r e i s n o Pa ge 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 S c h e d u l e A )

SCHEDULEA MONETARY( R e v . 0 7 1 0 3 ) RECE I P TS0 CHECKT HI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAMEAND ADDRESS OF CONTR I BUTOR RELAT I ONSHI P AMOUNT 4 I F FORECE I VED ( i f a p p l i c a b l e ) TO CANDI DATE' R ECEI VED FUND( MM/ DD/ YR ) A ND P AC CHECK ( i f a p p l i c a b l e ) RAI SENUMBER I NCOM

I D# ( p i - L ' ! 7- _77777^ ~- ' 7 g e t A T Z ; v ~ i Y i T t `z O l 3 r ' i c ~ N,wr l 1 ' f ST : s7~ 1 ~ 4 ~Q I D# ( , 05 t f - ' * 44 r SS ~~2 ~ ~ o J t ' ! I

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THI S BOXAPPLI ES TOCANDI DATES' COMMI TTEES ONLY :P u 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 n Sc h e d u l e H ( Re 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 pe nd 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 mus t a l s o b e d e t a i l i t e m i z e d o nSc 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 nd d a t e o f e a c h t y p e o f e x pe nd i t u r e mad e b y t h e p er s o Ne nt i t y o n b e h a l f o f t h e c a nd i d a t e ' s c o mmi t t e e . ( R e f e r t oSc 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 Code 68A . 4 0 2 ( 3 ) ( ) . )

( f o r Sc h e d u l e B)

FOR I NSTRUCTI ONS, SEE BACKOF FORM R e s e t Fo r m SCHEDULEEXPENMTURES B MONETARY-MONEYSPENT FROMCOMMI TTEEACCOUNT ( Re v . 0 7 / 0 3 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FORCONTRI BUTK) NSMADE TOSTATEWI DEOR LEGI SLATI V ECANDI DATES, L I STTHE CANDI DATE I DENT I F I CATI ON NUMBER I N THE DESI GNATED COLUMN ANDTHE CHECKTHI S BOXI FPACCHECKNUMBER FOR EACHEXPENDI TURE. A L I STOF I D NUMBERS I S AVA I L ABL E FROMTHE I OWA AMENDI NGFORMETHI CS & CAMPAI GN DI SCLOSURE BOARD.COMMI TTEE NAME ( Mu s t b e same a s o St a t e me n t y of Or g a n i z a t i o n)

CANDI DATE NAME ANDADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( Di s b u r s e me n t ) WASMADE( MMI DDYR) AND PACCHECKNUMBER/ o l 4 b 4 I D# ' 7; , b t e - - C 41 )( t a tCK#

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