Zirkelbach Raymond1535scanned

8/7/2019 Zirkelbach Raymond__1535__scanned

http://slidepdf.com/reader/full/zirkelbach-raymond1535scanned 1/4

FQRI NSTRUCTI ONS, SEEBACKOF FORM

DI SCLOSURE SUMMARY PAGE

COMMI TT EE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f O r g a n i z a t i o n )

A

I MPORTANT : I n d i c a t e b y # t y p e o f c o m m i t t e e y o u a r e r e p o r t i n g f o r : U U -L 1U ( - UUU

( 1 ) S t a t e * i d e / L e g i s l a t i v e / J u d g e S t a n 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 ) S t e PAC( 3 ) S t a t e Pa r t y t e

( 4 ) C o u n t y C e n t r a l Co mmi 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 d i d a t e NP t h e ryi sI I T - EVI B o a r d o r 0Ir~-P 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 t o:-~~

I AMF I L I N G A

[ : ] CI - E~ I F AME] NDMENT TO REPORT DATED

SUBTRACT TOTAL MONEY SPENT TH I S PERI OD

0Chec 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 mus 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 i l e d . )

L a t e r e p o r t s a r e s u b j e c t t o p o s s i b l e c i v i l a n d c r i m i n a l p e n a l t i e s . P u r s u a n t t o l o w a Code s e c t i o n 6 8 B . 3 2 A ( 7 )

t h e c a n d i d a t e , f o r a c a n d i d a t e ' s c o mmi t t e e , a n d t h e c h a i r p e r s o n , f o r a n y o t h e r t y p e o f c o mmi t t e e , i s t h e

i n d i v i d u a l r e s p o n s i b l e f o r f i l i n g t i m e l y a n d a c c u r a t e r e p o r t s .

SI GNATURE OF PERSON FNJNG REPORT TELEPHONE DATE SK94ED

PB3 0RT FOR ( 1 ) ELECTI ON / ( 2 ) NON- ELECTI ON YEAR.

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

STATEMENT OF CASH ON HAND

CASH ONKAMa 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 e

c o mm i t t e e . T h i s amoun t MUST b e t h e s ame a s t h e c a s h o n h a n d a t t h e e n d

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 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 TOTALMONEYTAKEN I N T HI S PERI OD

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 e e i n - k i n d b e l o w ) . . . . . . . . . . . . . . . . . . . . . . .

S c h e d u l e F . L o a n s R e 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 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

S 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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( Sc h ed u l e H a p p l i e s t o Ca n di d a t e s ' Co mmi f t e e s On l y )

SUB- TOTAL . . . . . . . . . . . . . . . . . . . . . . . $

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 8 ) ( - 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 Rep a 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 HI AND a t t h e e n 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 t

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

* * UNPAI 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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ -

I N K I ND CONTRI BUTI ONS ( F r 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 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ -

" OUTSTANDI NG LOANS ( F r o m S c h e d u l e F - A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ -

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

CANDI DATE CONI MI TTEES ONLY,

VALUE OF CAMPAI GN PROPERTY ( F r 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)

STATE COMI MI TTEES ; S u b mi t a r e c o n c i l e d c a mp a i g n a c c o u n t b a n k s t a t e m e n t i n J a n u a r y o f e a c h y e a r .

F ORM

DR- 2 I DI SCLOSURE

( Re v . 1 2 / 2 0 0 5 ) REPORT

For Of f i c e UseOP-1y

Comm . #

L o g g e d I n

S c a n n e d

C o mp u t e r

A u d i t e d

F i l e v A t h :

I o w a E t h i c s a n d Campa i g n

D i s c l o s u r e B o a r d5 1 0 E . l e , S t e . 1 ADe s Mo i n e s , I o wa 5 0 3 1 9

F a x : 5 1 5 - 2 8 1 - 3 7 0 1

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 mmi t t e e s , e n t e r Co u n t y i n

w h i c h E l e c t i o n i s h e l d

t 1q0 . o o

0

t5c t 4 5- C )

S u b d i v i s i o n PAC I I I I L o c a l B a l l o t I s s u e

CAN~WATI E

Can Name 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 )Ne

ID&0 1 0 ~J

D i s t r i c t ( i f S en a t e o r H o u s e )



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 r n

CONTRI BUT I 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 o n S t a t e me n t o f O r g a n i z a t i o n )

I ,5 f i Y7~&LIbO&

XOe t f o r m' lSCHEDU E

A I MONETARY

( Re v . 0 7 / 0 3 ) RECEI PTS

CHECK T HI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOT J : I F A CONTRI BUT I ON I S RECEI VED FROM A STATE PAC ( P O L I T I C AL ACT I ON COMMI T T E E ) , L I S T T HE PAC I D EN T I F I C A T I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COL UMN . A L I S T OF i D NUMBERS I S A VA I L A B L E FROM THE I OWA E T H I C S AND CAMPAI GN

DI SCLOSURE BOARD.

CAU T I ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Co de , 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 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 g e o f t h i s s c h e d u l e )

' D i s c l o s u r e l o w r e q u i r e s c a n d i c l 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 m u s t b e s h ow 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 ame 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 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 u mn . d u l e A )

DAT E PAC I D NUMBER NAME AND ADDRESS OF CONTR I BUTOR REL AT I ONSHI P AK4 0 UNT 4 I F FORECEI VED ( i f a p p l i c a b l e ) T O CANDI DATE* RECEI VED FUND-( MM/ DDNR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SER

NUMBER I NCOM

I D#

ACK# l q 6 1 1 4 0 A I N , We 9 W

I d Of t wi ~ 10, CI X015 -

31q/ 0&

I D#

CK#

t0l pp-

0 2FAL PI r mMIt~

FWWf

I D#

CK#

4 i l00

W -

I D#

CK#

-r A 1 0E~]

I D#

CK#0 1 1

I D#

CK#00

NaW =AW1J b5 -I D#

~ 3̀9Z e oCK# 1 ~I D#

CK# -O d k l a s , x j -W~ I K4

I D#

0 1 ) E Z ICK#

9/ 1 ~ / Oz ~

I D #

CK # gj ) , 0, 9

L



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 - - MONEYTAKEN I N

( I n c l u d i n g c a nd 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 as o n St a t emen t o f O r g a n i z a t i o n )

STATE CANDI DATES NOTE : 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 AT I ONNUMBER AND T HE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S A V AI L A B L E FROM THE I OWA E T HI C S AND CAMPAI GN

DI SCLOSURE BOARD

CAUT I 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 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 an y c omme r c i a l p u r p o s e b y an 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 ommi t t e e s

SCHEDULE

A MONETARY

( Re v . 0 7 1 0 3 ) RECEI PTS

CHECK T 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 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 m a k i n g a c o n t r i b u t i o n t o t h ec o m m 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 ym 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 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 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 .

SUB- TOTAL

f t h i s s c h ed u l e )I V I AL ( i t i d s , p a g e o

Pa ge o f

( f o r S c h e d u l e4 A

DATE PAC I D NUMBER NAMEAND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT 4 I F F ORECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECEI VED FUND-( MM/ DD/ YR ) AND PAC CHECK ( i f a p p l i c a b l e ) RA I SE

NUMBER I NCOM

I D4

0 - 9 5Z J o a n1 4CK#

I D#

CK# / Ox( OK 1 9

I D#

CK#r

I LI D#

C(

CK# 7

I D#

c K#

I D# P a t e , a n6t J w~

r , " - ~ w f f

/ 1 0 1 -k' " Y

O' s -

CK#. 1

4V&1wGa , - T -4 5 -0 0 I D5 -

I D# d wt o Co -

T&X&VCK#

, L jT x _ 1

I D#4 9

qoo SMA%CK#

I D#

CK#

I D#

CK#



E* wx b upm t o ; A I N p mv f t q o c r A t o l i f t a dmi l e f t Wmk mk f t I 0 g n wwo i & r V - I d q 2 , wwd a b o b e d o Wkwnkmd o n

Sdodub0b y t o nv KwK p w p o w a n d d e f t d am c h t o o da i wo dk f f o ? l b y 1 w p o w s o r d w r i f t y a n b o l df t c wv A k Ws o mwf t n . ( PA%r l o

Sdwdub G k u t wc f t w a i d i mmCode 0&4 02 0W)

FORWSTRUCTM04 SEEMCKOF FORW

STATEPAC CONNOTT I M 1 01 FOR C ON T 1 1 1 1 1 1 P U T I O NS OMMTO STATEWI DE ORLEGI RATMECANDI DATES, L I S T THE CANDVATE I DEPOWATI OWMKOMWTHE OSSI GMI MOMARMAND TMPAC CHEMNUMBEI R FOR EACH E XP E N DI T L I F I E . A USTOF I DMUNOM0AVARA" PWOTHE K I WAETHI CS & CAMPAMMDNXXCSU14EBOAM

( I mSdmdLde 8 )

Zirkelbach Raymond__1535__scanned

Documents

Zirkelbach Raymond1535scanned