Report Du e Date : 01/19/2002 Commi t t ee Chair : J o Anne Ham e s Status : Or i g Count y : Scott Notice of Dissolution : N/ A S t a t e me n t o f Cash O n Han d Ad d i t i o n al Asset s an d Liabilities Orig (319) 285-9716 This Report W as Pr i n t e d Wi t h The I CFRS So f t war e o n 01119/2002 10:33:50 AM Cash On Hand at St ar t of Period $394 . 9 9 Schedule A: Cash ContributionsTotal $2,100 . 0 0 Schedul e F : Loans Received Total $1,750 . 0 0 Schedul e H : Campai gn Property Sales $ 0 . 0 0 SUB- TOTAL $4,244 . 9 9 Schedule B : Expenditures Total $2,385 . 3 8 Schedule F : Loan Repayment s Total $1,750 . 0 0 Cash o n Hand At En d o f Period $109 . 6 1 Loans i n Place a t Start o f Period $ 0 . 0 0 Schedul e D : Un P a i d Bills $ 0 . 0 0 Schedule E : In-Kind Contributions $ 0 . 0 0 Schedul e F : Outstanding Loans $ 0 . 0 0 Schdul e G Consultant Breakdown? No Schedule H : Campai gn Property Value $ 0 . 0 0 Forgiven Loans (From Schedule E ) $ 0 . 0 0 FO RM DR- 2 : Disclosure Summar y rage I D :1224 O R M DR- 2 DI SCLOSURE I CFRS 4/98 REPORT For Offi c e Us e On l y ',ounty : Sc ot t Type : St at e Hou se Co m m . # " " ' 1224 Treas : Mi chael He i n (319) 284-6726 Indexed Name : Si evers F o r St at e Ho u se Audited Comput er Co ~-
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T h i s Re p o r t Was Pr i n t e d Wi t h Th e I CF RS So f t wa r e o n 0 1 1 1 9 12 0 02 1 0 : 3 4 : 5 9 AM
P a g e T o t a l $ 8 5 0 .
P a g e 1 o f
( f o r s c h ed u l e
SCHEDULE A Co n t r i b u t i o n s - Mono - T a k e n I n SCHEDULE
I D 1 2 2 4MONETARY
RECE I PTSName Si e v e r s Fo r S t a t e H o u s e I CFRS 1 2 / 9 9
ORI GI NAL
T y p e S t a t e H o u s e
Co mmi t t e e I D
Da t e R e l a t i o n s h i p Amo u n t
Re c e i v e d Ch e c k # Name a n d Ad d r e s s o f C o n t r i b u t o r To Ca n d i d a t e Re c e i v e0 1 / 0 5 / 2 0 0 1 I D 6 1 0 1 Mo t o r C a r r i e r s PAC: $ 2 5 0 .
Ch : 2 1 0 97 1 7 E . Co u r tDes Mo i n e s I A 5 0 3 0 9 4 9 0 1
[ # 7 5 7 ] A0 6 / 0 4 / 2 0 0 1 I D : 6 1 0 1 Mo t o r C a r r i e r s PAC: $ 1 0 0 .
C h k # 10 9 17 E . Co u r tDe s Mo i n e s I A 5 0 3 0 9 4 9 0 1
EXPLANAT I ON : PAC F u n d r a i s e r
[ # 7 8 5 ]
0 6 / 0 5 / 2 0 0 1 I D : 6 2 9 1 I o wa H o s p i t a l As s oc i a t i o n P o l i t c a l Ac t i o n Co mmi t t e e No Re l a t i o n $ 1 0 0 .
C h k # : 1 7 6 0 10 0 E . Gr a n d Su i t e 1 0 0De s Mo i n e s I A 5 0 3 0 9
EXPL ANATI ON : PAC F u n d r a i s e r
[ # 7 7 6 ]
0 6 7 / 2 0 0 1 I D : 6 0 7 3 I o wa Me d i c a l P o l i t i c a l A c t i o n Co mmi t t e e $ 1 0 0 .
C h k # : 3 5 01 0 0 1 Gr a n d Av e n u e
We s t De s Mo i n e s I A 5 0 2 6 5 3 5 0 2
EXPL ANATI ON : PAC F u n d r a i s e r
[ # 7 7 4 ]
0 6 / 0 8 / 2 0 0 1 Wi l s o n , Geor geA. No R e l a t i o n $ 5 0 .
C h k # : 1413 03 1 7 S i x t h A v e n u e Su i t e 7 4 0
De s Mo i n e s I A 5 0 3 0 9 4 1 1 4
EXPL ANATI ON : PAC F u n d r a i s e r[ # 7 7 1 ]
0 6 / 1 0 / 2 0 0 1 mod , Mona R. No R e l a t i o n $ 1 0 0 .
C h k # : 5 7 6 3 2 8 1 8W. 1 s t S t r e e t
A n k e n y I A 5 0 0 2 1
EXPL ANATI ON : PAC F u n d r a i s e r
[ # 7 7 2 ]
0 6 / 1 1 / 2 0 0 1 I D : 6 0 2 1 Cr e d i t Un i o n PAC $ 1 0 0 .
C h k # : 1417P . O . Bo x 1 0 4 0 9De s Mo i n e s I A 5 0 3 0 6 0 4 0 9
EXPL ANATI ON : PAC F u n d r a i s e r
[ # 7 7 5 ]
0 6 / 1 1 / 2 0 0 1 I D : 6 0 3 4 En g i n e e r sC $ 5 0 .
C h k # : 14391 0 0 0 Wa l n u t S t r e e t , S u i t e 1 0 2
T h i s Re p o r t Was P r i n t e d Wi t h Th e I CF RS So f t wa r e o n 0 1 1 1 9 1 2 0 0 2 1 0 : 3 5 : 0 0 AM ( f o r s c h e d u l e A
SCHEDULE A C o n t r i b u t i o n s - Mon T a k e n I n SCHEDULE
I D 1 2 2 4MONETARY
RECE I PTSName : Si e v e r s Fo r S t a t e H o u s e I CFRS 1 2 / 9 9
ORI GI NAL
T y p e : S t a t e H o u s e
Commi t t e e I D
Da t e R e l a t i o n s h i p Amount
Re c e i v e d Chec k # Name a n d Ad d r e s s o f C o n t r i b u t o r To Ca n d i d a t e Re c e i v e6 / 1 8 / 2 0 0 1 I D : 6 0 6 9 I o w a i n d u s t r y P o l i t i c a l A c t i o n Commi t t e e ( I I I F FAG) - -$50
Chk# 1 8 0 0 9 0 4 Wa l n u t - S u i t e 1 0 0
De s Mo i n e s I A 5 0 3 0 9 3 5 0 3
EXPLANATI ON : PAC F u n d r a i s e r[ # 7 78 ]
0 6/ 2 9/ 2 0 01 I D : 6 0 2 7 De e r e PAC I o wa No R e l a t i o n $ 2 0 0 .
Chk# : 1 8 2 26 6 6 Gr a n d A v e n u e S u i t e 1 7 0 7
De s Mo i n e s I A 5 0 3 0 9 2 5 0 7
EXPLANATI ON PAC F u n d r a i s e r[ # 7 8 6 ]
0 9/ 1 3 / 2 0 0 1 I D 6 4 1 1 MCI I OWA PAC $ 1 0 0 .
Chk# : 1 1 4 7 1 9 2 5 Bo y r u m S tI o wa C i t y I A 5 2 2 4 0
EXPLANATI ON C o n t r i b u t i o n
[ # 7 9 4 ]
0 / 2 0 01 I D 0 g?) WL a f a r g e PAC No R e l a t i o n $ 1 0 0 .
Chk# 1 4 1 81 1 1 3 0 S u n r i s e V a l l e y Dr . S t e 2 0 6
T h i s Re p o r t Was Pr i n t e d Wi t h T h e I CFRS So f t wa r e o n 0 1 11 91 2 0 0 2 1 0 : 3 5 : 1 3 AM ( f o r s c h e du l e B
SCHEDULE B : Ex p en d i t u r es -- - Mo r - Spe n t F r o m Co mmi t t e e A c c o u n t D I V
BMONETARY
0: 1 2 2 4 EXPENDI TURES
Name Si ev e r s F o r S t a t e Ho u s eI CFRS 1 2 / 9 9
ORI GI NAL
T y p e S t a t e Ho u s e
Da t e Commi t t e e Name a n Ad d r e s s o Whom E x p e n d i t u r e mo wn x p e n . eE x p e n d e d Check # ( D i s b u r s e m e n t ) Was Made
0 1/ 0 7/ 2 0 0 1 Kn o t t P r i n t e r s $ 4 8 1 . 3
Chk# : 1108
Mu s c at i n e I A 5 2 7 6 1
# 7 5 9 ] PRI NT I NG & REPRODUCTI ON : P r i n t i n g Campa i g n M a t e r i a l
0 1/ 0 7/ 2 0 0 1 V i c t o r y En t e r p r i s es $860 . 0
Chk# : 1109
Da v e n p o r t I A 5 2 8 0 2
# 7 5 8 ] HOEXPENSES : Web S i t e d e s i g n a n d h o s t i n g
0 1/ 2 8 / 2 0 0 1 Po s t ma s t e r $32 . 0
Chk# : 1110 New L i b e r t y P o s t O f f i c e
New L i b e r t y I A 5 2 7 6 5
# 7 6 0 ] POSTAGE, SHI PP I NG, DEL I VERY : P . O . Bo x R e n t a l
0 7/ 0 3 / 2 0 0 1 I D : 1224 B r y a n Si e v er s $74 . 1
Chk# : 1112 27135 1 s t Av en ue
New L i b e r t y I A 5 2 7 6 5
# 7 6 8 ] I N TEREST ON LOAN : I n t e r e s t o n L o a n f r o m C a n d i d i a t e ' s Own Fu n d s
0 7/ 1 7/ 2 0 0 1 I D : 1224 Br y a n Si e v er s $35 9 . 0
Chk# : 1114 27135 1 s t Av en ue
New L i b e r t y I A 5 2 7 6 5
# 7 8 8 ] OTHER EXPENDI TURE : Re i mbu r semen t f o r We b s i t e Fees $ 1 5 0 . 0 0 , N o r t h S c o t t P r e s s $ 1 4 0 . 0 0 a n d D1 $6 9 . 0 0 .
0 7/ 1 7/ 2 0 0 1 V i c t o r y En t e r p r i s es $30 . 0
Chk# : 1113Da v e n p o r t I A 5 2 8 0 2
# 7 8 9 ] OTHER EXPENDI TURE: We b s i t e m o n t h l y f e e
0 8 / 1 2 / 2 00 1 V i c t o r y En t e r p r i s es $ 3 0 . 0
Chk# : 1115
Da v e n p o r t I A 5 2 8 0 2
# 7 9 0 ] OTHER EXPENDI TURE : M o n t h l y We b s i t e Fees
0 9/ 1 4/ 2 0 01 I D : 1224 B r y a n Si e v er s $109 . 9
Chk# : 1116 27135 1 s t Av en ue
New L i b e r t y I A 5 2 7 6 5
# 7 9 3 ] MEALS REI MBURSEMENT : 2 0 Mea l s f o r R i v e r Re n a i s s a n c e Me e t i n g
T h i s Re p o r t Was Pr i n t e d Wi t h Th e I CF RS So f t war e o n 0 1 1 1 9 1 2 0 0 2 1 0 : 3 5 : 1 3 AM ( f o r s c h ed u l e B )
SCHEDULE B Ex p en d i t u r e s - - Monev Sp e n t Fr o m Co mmi t t e e A c c o u n t SCHELL LE-- MONETARY
BI D 1 2 2 4 EXPENDI TURESI CFRS 1 2 / 9 9
Name S i e v e r s Fo r S t a t e H o u s eORI GI NAL
T y p e : S t a t e H o u s e
Da t e Commi t t e e 1 0 Name an d Ad d r e s s 1 5 Whom E x p e n d i t u r e Amou n t E x p e n d e e iE x p e n d e d Che c k # ( D i s b u r s e m e n t ) Wa s Mad e
V i c t o r y E n t e r p r i s e s $ 3 0 . 0 0
Chk# 1 1 1 7D a v e n p o r t I A 5 2 8 0 2
OTHER EXPENDI TURE : Mo n t h l y Web S i t e H o s t i n g
1 2 / 2 0 01 V i c t o r y En t e r p r i s es $30 . 00
Chk # : 1 1 1 8
Da v e n p o r t I A 5 2 8 0 2
OTHER EXPENDI TURE: Web S i t Fees
1 9 / 2 00 1 Y 4 0 St o r a ge $2 8 8 . 9 0
Chk # : 1 1 1 9 Bo x 2 6 1
Wa l c o t t I A 5 2 7 7 3
OTHER EXPENDI TURE : R e n t a l U n i t f o r Y a r d S i g n s
1 2 / 2 0 01 I D : 1 2 2 4 Br y a n S i e v e r s $ 3 0 . 0 0
C h k # : 1 1 2 0 2 7 1 3 5 1 s t A v e n u e
New L i b e r t y I A 5 2 7 6 5
OTHER EXPENDI TURE: Rei mb u r s eme n t f o r Mo n t h l y Web S i t e Fees
1 4/ 2 00 1 V i c t o r y En t e r p r i s es $30 . 00
Chk # : 1 1 2 1Da v e n p o r t I A 5 2 8 0 2
OTHER EXPENDI TURE : Mo n t h y We b S i t e f e e s
I D : 1 2 2 4Name Si e v e r s Fo r St a t e House
T y p e St a t e House
SCHEDULE
FI CFRS 1 2 / 9 9
LOANS
RECEI VED& REPAI D
ORI GI NAL
T o t a l Un p ai d L oan s F r om L a s t R e p o r t i n g P e r i o d $ 0 . 0 0
PART - MONETARY LOANS RECEI VED T HI S REPORTI NG PERI OD
SCHEDULE F L o a n s Re c e i v e d & Re p ai dTOTAL LOANS RECEI VED T HI S PERI OD ( P a r t I ) : $ 1 , 7 5 0 .
PART I I - MONETARY LOAN REPAYMENTS MADE T HI S REPORTI NG PERI OD
SCHEDULE F L o a n s Re c e i v e d & Re p a i dTOTAL L OAN REPAYMENTS T HI S PERI OD ( P a r t I I ) $ 1 , 7 5 0 .
Fr o m Sc h e d u l e E - TOTAL LOANS FORGI VEN
TOTAL OUTSTANDI NG LOANS END OF REPORT PERI OD
$ 0 .
$ 0 .
ORI GI NAL
T h i s Re p o r t Was P r i n t e d Wi t h T h e I CF RS S o f t w a r e o n 0 1 1 1 9 1 2 0 0 2 1 0 : 3 5 : 2 5 AM
Page 1 o f
( f o r s c h e d u l e F )
Da t e Name an d Ad d r e s s o f L e n d ae r R e l a t i o n s h i p To Amou n t o fRe c e i v e d ( I n c l u d e E n d o r s e r ' s Name, I f A p p l i c a b l e ) Ca n d i d a t e L o a n
Ca n d i d a t e s P e r s o n a l F u n d s$ 1 , 7 5 0 .
0 1 / 0 5 / 2 0 0 1
# 7 6 1 ENDORSER : B r y a n S i e v e r s P e r s o n a l Che c k # 1 4 2 3 6 e n d or s e d b y Re p . B r y a n S i e v e r s
Da t e
P a i d
Name a n d Ad d r e s s o f L e n d ae r
( I n c l u d e E n d o r s e r ' s Name, I f A p p l i c a b l e )
R e l a t i o n s h i p T o
C a n d i d a t eAmount
Re p ai d
0 4 / 0 7 / 2 0 0 1
C a n d i d a t e ' s P e r s o n a l F u n d s$ 7 5 0 .
# 7 6 4 ENDORSER : B r y a n S i e v e r s - Ch ec k # 1 03 3
0 7 / 0 3 / 2 0 0 1C a n d i d a t e ' s P e r s o n a l F u n d s
$ 1 , 0 0 0 .
# 7 6 7 ENDORSER : B r y a n S i e v e r s - Check # 1 1 1 1