10-29-04 0 9 : 2 4 TRI - COUNTY BANK AND TRUST MONT F OR' I NSTRUCTI ONS, SEESACK O . ) RM DI SCL OSURE SUMMARY PAGE C OMMI T T E E NAME ( Mu s t b e s a me a s o n St at ement o f Organization) L ;Lcn_S L - ZP,-_1,4r~ I MPORTAN . ndlcate b y # type o f c o mmi t t e e y o u a r e reporting f o r ~ ~ ( 1 )StatewIdelLegislative/Judge Standin tention Candidate ( 2 )State PA C ( 3 )State Pa r t y ( 4 )County Central C o mmi t t e e ( 5 )Cou e )City Candidate ( 7 ),School Board o r Other Political SubdlvlsbnCandldate ( 8 ) C c t y 1 0 )School Board o r Other Political Subdivision PA C ( 1 1 ) Local Ballot I s CANDI DATE COMMI TTEES ON Candidate Na me 2 ; Office Sought V 7 SI GNATURE J W WPERSON F IL REPORT I AM FILING A ~G-tn . r - (repon date) EI CHECK I F AMENDMENT TO REPORT DATED ADD TOTAL MONEY TAKEN I N THI S PERI OD I D=3194656177 3 / 9 = y x sL3zz K TEL EPHONE 0Check i f this i s final (termination) report a n d attach Notice o f Dissolution Fo r m DR- 3 . (You must continue t o file reports until a DR- 3 I s filed . ) STATEMENT OF CASH ON HAND Comm. # Logged I Scanned Computer Audited Late reports aresubject t o possible civil a n d criminal penalties . DATE SI GNED -REPORT FOR ( 1 ) ELECTI ON l ( Z} NON" ELECTI ON YEAR. Indicate b y ' ( ~ ` ~ # Local Committees, enter Date o f Election County & Local Committees, enter County i n which Election i s held CASH ON HAND a t t h ebeginning o f t h e reportingperiod . (Total of a l l funds held b y t h e c o mmi t t e e . This amount MUST be the same a s t h e cash o n hand a t th e pnd~ o f t h e last reporting period o r mus t be zero I f this I s first report flied . ) . . . . 5 ! . . Schedule A : Cash Contributions total (Attach Schedule A ) ('also s e e in-kind below) . . . ...... 9y 7 . Schedule F - Loans Received total (Attach Schedule F ) . . . . ........ ...... . . . . . . . . . . . .......... . . ..... . . . .... 0 Schedule H : Total Sales o f Ca mp a i g n Property (Attach Schedule H) ..... . ..... .... . . . ...... . ...... . . _(Schedule H applies t o Candidates' Commi t t ees On l v ) SUS- TOTAL . . . . . $ SUBTRACT TOTAL MONEY SPENT THI S PERI OD Schedule B : Expenditures total (Attach Schedule B ) ("also s e e debts a n d loans below) . _ _ . Schedule F : Loan Re p a y me n t s total (Attach Schedule F ) . . . . . . . . . . . .......... ............. . . . . . . ...... CASH ON HAND a t t h e e n d o f this reportingperiod ( I f final report balance muss~ ~ : b e zero) (Attach DR- 3 ) . . . .... . . . .......... . _ . . . _ . . _ . . . . . . . . ...... . .......... . . . . . . . . ~ : . . . . . r 7 . . . . ~ . . _ _ . _ .... . . $ ss , 7 8 s s ` l y 7 ' 963' 0 0 " UNPAI D BI L L S (From Schedule - Attach Schedule D)____ .......... . . ...... . .... . .... . , . . . . . . , .... . . . .... . _ . . . . , . , . . $ n " I N K I ND C ON T RI B UT I ONS ( Fr o mSchedule E - Attach Schedule E ) .... . . . . . . . ...... . . . . . ...... . ............... . . $ 6 , . y6 q ' . og " OUTSTANDI NG L OANS (FromSchedule F- At t a c h Schedule F ) .... . .... . ............ . . . ........ ...... . . . . . . . . . . $ CANDI DATE C OM MI T T E E S ONL Y: CONSUL TANT BR EAKDOW N (Schedule G Attached?) VAL UE OF CAMPAI GN PROPERTY ( Fr o m Schedule H - Attach Schedule H ) P . 0 2
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1 0- 2 9- 0 4 09 : 24 TRI - COUNTY BANK AND TRUST MONT
FOR' I NSTRUCTI ONS, SEESACKO. ) RM
DI SCLOSURE SUMMARY PAGE
COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t emen t o f O r g a n i z a t i o n )
L ; L c n_ S L - Z P , - _ 1 , 4 r ~I MPORTAN . n d l c a t e b y # t y p e o f c o mm i t t e e y o u a r e r e p o r t i n g f o r ~~( 1 ) S t a t e w I d e l L e g i s l a t i v e / J u d g e S t a n d i n t e n t i o n C a n d i d a t e ( 2 ) S t a t e PAC ( 3 ) S t a t e Pa 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 e ) C i t y C a n d 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 l v l s b n C a n d l d a t e ( 8 ) C c t y 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 l
S 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 sCANDI DATE COMMI TTEES ON
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STATEMENT OF CASH ON HAND
Comm . #
L o g g e d I
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DATE SI GNED
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I n d i c a t e b y '(~` ~
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L o c a l C o mmi t t e e s , e n t e r D a t e o f E l e c t i o n
C o u n t y & L o c a l C o mm i t t e e s , e n t e r C o u n t y i nw h i c h E l e c t i o n i s h e l d
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 amoun t MUST be t h e same a s t h e c a s h o n h a n d a t t h e pnd~
o 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 mus t be z e r o I f t h i s I s f i r s t r e p o r t f l i e d . ) . . . . 5 ! . .
S c h e d 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 S c h e d u l e A ) ( ' a l s o s ee i n - k i n d b e l o w ) . . . . . . . . . 9 y 7 .S c h e d u l e F - L o a n s Re c e i v e d t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0S c h e d u l e H : T o t a l S a l e s o f Campa i g n P r o p e r t y ( A t t a c h S c h e d u l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
_ ( S c h e d u l e H a p p l i e s t o C a n d i d a t e s ' Commi t t e e s On l v )
SUS- TOTAL . . . . . $
SUBTRACT TOTAL MONEY SPENT THI S PERI OD
S c h e d 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 S c h e d u 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 ) . _ _ .
S c h e d u l e F : L o a n Repa y men t s t o t a l ( A t t a c h S c h e d 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 f f i n a l r e p o r t b a l a n c e m u s s ~~
:b e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . _ . . . _ . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~: . . . . . r 7 . . . . ~ . . _ _ . _ . . . . . . $
s s , 7 8 s s ` l
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" UNPA I D BI L L S ( F r o m S c h e d u l e D - A t t a c h S c h e d u l e D ) _ _ _ _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . , . . . . . . . . . . . . _ . . . . , . , . . $ n
" I N K I ND CONTRI BUTI ONS ( Fr o mS c h e d u l e E - A t t a c h S c h e d u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 6 y , . y6 q ' . og
" OUTSTANDI NG LOANS ( F r o m S c h e d u l e F- At t a c h S c h e d u 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 ( Fr o m S c h e d u l e H - A t t a c h S c h e d u l e H )
10-29-04 09 : 25 TRI -COUNTY BANK AND TRUST MONT ID=3194656177 P . 03
Fo r I h s t r u c t i o ns , See Back o f Fot
CONTRIBUTI ONS- - MONEYTAKENI 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 TTEENAME( Mu s t b e s ame a s o n S7a t emen t o f Or g a ni z a t i o n)
64I ' ~eyxs LCr r l l r l ~~
STATECANDI DATES NOTE: I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THEPAC I DENT I F I CATI ONNUMBER ANDTHEPACCHECKNUMBER I N THEDESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LA B LE FROMTHEI OWA ETHI CS AND CAMPAI GNDI SCL OSURE BOARD.
CAUTI ON . Se c t i o n 68B. 3 2 A ( 6 ) , I o wa Coda , p r o h i b i t s t he u se o f I n f o r ma t i o n c o pi e d f r o m r e p or t s an d s t a t e me nt s f o r s o l i c i t i n g o o n t r i b u t i o n e o r
f o r an y c omme r c i a l p u r p o s e by an y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c ommi t t e e s .
SUB- TOTAL
TOTAL ( I f l a st psgo o f t h i s s c h e du l e )
P l s c l o s u r e l aw r e q u i r e s c a n d i d a t e commi t t ees t o d i s c l o s e t h e r e l a t i o n e h l p o f an y r e l a t i v e mak i n g a c o n l r l b u t l o n t o t h e
c ommi t t e e . R e l s t l o n s h i p must b e s h o wn t o t h e t h i r d d e g r e e o f o on ae n g ul n l y ( b l o o d r e l a t i v e s ) an d v f n l t y ( r e l a t i v e s by
m a r r i a g e ) . I f s u r n ame 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 no P a g e _j o f
f 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 umn . ( f o r Sc h e d ul e A)
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Fo r I n s t r u c t i o ns , Se e B a c k o f F o .CONTRI BUTI ONS - MONEY TAKEN I N
( I n c l u d i n g c a n d i d a t a ' e p e m o m l t u n e s )
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STATE CANDI DATES NOW: I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P O L I T I C A L ACTI ON COMMI T T E E ) , L I S T THE PAC I D EN T I F I C A T I O NNUMBERAND THE PAC CHECKNUMBER I N THE DESI GNATED COLUMN_ A L I S T OF 1 0 NUMBERS I S A V A I L A B L E FROMTHE I OWA E T HI C S AND CAMPAI GNDI SCLOSURE BOARD.
CAUT I ON : Se d l o n 6 8 B _ 3 2 A ( B ) , I o wa Co d 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 d o n o o p l e d f n x n r e p o r t ; a n d s Ma 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 r n me r d 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 en s t a t u t o r y p o i t d c a l c o mmi t t e e s .
SUB- TOTAL
TOTAL ( i f l a s t pwoo f d r i s a c l r e d u l e )
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2 ,50
c o mm i t t e e . R e l a t i o n s h i p m u s t b e s h o wn t o me t h i r d d o gma o f o o r w a n g u t n l t y ( b l o o d r a l a t i v e e ) a n d a f i n l t y ( r e l e t l v s s b yma r r i a g e ). I f s u ma r n e o f c o n t r t t 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 of a m i l i a l r e l a b o n e 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 s f o n s h i p c o l u mn _
Page _1( f o r S d t e d u t e A )
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P - AMOUNT J I F F ORECEI VED ( I f a p p l i c a b l e ) TO CANDI DATE' RECEI VED F UN f l -( MM/ DDI YR) AND PAC CHECK ( I f a pp l i wb l e ) RA I SE
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T H I S BOX APPUES TO C A ND I D A T E S ' COMMI TTEES O N L Y _
EXPENDI TURES - - MONEY SPENT FROM COMMI TTEE ACCOUNT
S T A T E P A C C OMMI T T E E S : NO TE : F OR C ON T R I B U T I O NS M A D E T O S T A T E WI D E ORL E GI S L AT I V eC A ND I D AT E S , US T T H E C A ND I D A T E I DE NT I F I C AT I ON NUMBER I N T HE D ES I G NA T E D C OL U M N A N D T H EP A C C H E C K NUMBER F OR E A C H E X P E N DI T U R E . A L I S T OF I D NUMBERS I S A V A I L A B L E FRO M T H E I O WAE T H I C S S C AMP A I G N D I S C L OS U RE B O A R D ,
SCHEDULE
B MONETARY4 ( R e v . 0 7 1 0 3 ) E X P E ND I T U R E S
CHECK T H I S BOX I FAMENDI NG FORM
P u r c h a s e s o f c e r t a i n c a m p a i g n p r o p e r t y c o s t i n g $ 6 0 0 o r m o r e m u s t a l s o b e i n v e n t o r i e d o n S c h e d u l e H ( R e f e r t o S c 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 l e s p r a v i d i n g c o n s u l t i n g , a d v o r l l e l n g , f u n d - r a i s i n g , p o l l i n g , m e n a p i n g , o r g a n l z l n g s e r v i c e s m u s t a l s o b e d e t a i l i t e m i z e d o nS c h e d u l e G b y t h e a m o 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 me p a r e W e n t l 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 m m i t t e e ( R e f e r t os c h e d u l e 0 k w t r u c x l o n e a n d I o w a C o d e 6 8 A _ 4 0 2 ( 3 ) ( n . )
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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 a t i n g $ 5 0 0 o r mo r e must a l s o b e I n v e n t o r i e d o n Sc h ed u l e H ( R e f e r t o Sc h e d ul e HI n s t r u c t i o n s , )
Ex p e nd i t u r e s t o P e r s O n a l e n f i l l e s p r o v i d i n g c o n s u l d n g , a d v e r t l s i n g . f u n d - r a l a l n g , p o t t i n g , ma n a g i n g , o r g a n t z l n g s e r v i c e s must a l s o b e d e t a i l I t e mi z e d o nSc h e d ul e G b y t h e a mo un t , p u r p o s e , a n d d at e o f e a c h t y p e o f e x p e n d i t u r e made b y t h e p e r s o nl e nt h 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 oSc h e d ul e GI n s t r u c t i o n s a nd I o wa Code 8 8A . 4 0 2 ( 3 ) ( I ) . )
p a g e -_a--_ Of _ _
( f o r Sc h e d ul e B)
FOR I NSTRUCTI ONS, SEE BACK OF FORM = " " U u SCHEDULE
B MONETARYEXPENDI TURES - MONEY SPENT FROM COMMI TTEE ACCOUNT ( R e v 0 7 1 0 3 ) E X P E N DI T U R E S
S T A T E P A C C OMMI T T E E S : NOTE : FORCONTRI BUT I ONS MADE TO STATEWI DEOR LEGMI AT I VEI F
CANDI DATES, L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN ANDTHE CHECK T H I S BOX
PAC CHECK NUMBER FOREACH EXPENDI TURE . A L I S T OF I D NUMBERS 1 9 AVA I LABLE FROM THE I OWA AMENDI NG FORMETHI CS &CAMPAI GN DI SCLOSURE BOARD .
COMMI TTEE NAME ( M u ; t t > , e same a s o men Or g a n i z a t i o n)
CAND ATE~ NAME AND ADDRESS TOWHOM PURPOSE AMOUNT
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COAAMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e n wn t o f
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QCHECKT HI 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 s t o d i a b l o s a 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 n i n k i n d c o n t r i b u t i o n t o t h e P a g e I o fc o mmi t t e e . R e l a t i o n s h i p m u 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 ( f o r S c h ed u l e E )b y ma r r i a g e ) . ( S e e P a g e 2 o f f o r m s p a c k e t . ) I f s umame 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 m n .
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NAME ANDADDRESSOF CONTRI BUTOR
RELATI ONSHI PTO CANDI DATE
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DESCRI PT I ONOF I N K I ND
CONTRI BUTI ON
ESTI MATEDF A I R MARKET
VALUE
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