FOR INSTRUCTIONS, SEE BACK OF FORM

CHECK ONE:
R This is an initial' Statement of Organization DEC 14 FORM STATEMENT

DR-1 OF
V' This is an amended' Statement of Organization (REV 0512005) ORGANIZATION
An inlflal . Stet$ment of Organization must be filed within 10 days ofthe committee s 8t owing Contributions, Far Office Use y
making expendltwes . or Incurring Indebtedness arteedtng 5750. Arnandrhente must be filed wiWn 30 days of Only
e
a change. Penalties may bo imposed foriate-filed lgtstwrlents # OrWizelioti. A - candiuate wkh an open Indexed
aornmiftse that exceeds $750 in activity for snorlw office shag file wifflhm 10 days allhor a new or emended Audited
DR-1 di3c lomng information concerning Me campaign for the new office sought.
Compu ter

COMMITTEE NAME 1 1

mandato exce t for a cand1date's committee

Name y y Name 1 1
_TeA n ne- ,,p`d c fin r'
Mailing Address ~ ~ Mail Address 1 1 ~1
~~ (. ClAQ% e C in sir f 1 1'~ a2 3D Sir o Q~- ~LF~.
City, Statc ,l l Zip C~od,,e 1 1

phone ( 3(1) 5g5 - ( 0D-7- Phone (3 11 ) ~L - 2-361-

etrmail $-Mail TOW-M-1 UNT10 Sow
INDICATEPURPOSE
Comment or descri "
All Candidates Enter
Office Sought: t~ P.
C' .l P&r- Cf"L Anrtar6-
Dlstrlci :

Political Parry (d applicable) lJ I A Year Standing for Election . .2 QQ (n

County/Local Candidates and Local BallotlFrenchise Committees Enter.

County : JQ"N Date of Election: 91141f)(4

Bank Account Name Candidate name 3 Addrysa or Parent Entity (PACs . if aoolloable .
1 1 Afflllam or8-porzao_r

CJAiT.sisS 4 , 4t, r rA J " rrP_

Name of Financial InstitulioMtype of Account 1 1 Malling Address 1 1

Tr" ~i~ A1n ' S 1~f Qkl

Mailing Address 1 1 City State 1 1 Zip 1 1

l o,~ tJ~, u`,¬o- 1 1

City 1 1 State 1 1 ZIp
Phone

®~ TA 5 a3 e-~A
e-Mail _

STATEMENT OF AFFIRMATION : By flung this document the committee affirms the following :

1 . The Committee and ell persona connected with the committee understand that they are subject to the laws In lava Code chapters W and 688 and the adminisirtmve
rules In Chapter 351 of the town Administrative Code .

2. That lov4 Code section 68A .402 and rule 351--4 .9 require the filing of disclosure reports and that the failure to file these reports on or before the required due dates
subjects the candidate cr chairperson (in the case of committees outer than a candidate's committee) to the automatic a3sessmem of e CINI penalty end me possible
imposition of other Criminal and civil sanctions.

3 . That love Code section 68A405 end rules 351-A .36 through 4 .43 require the placement of the words 'paid for by and fns name of the committee on all political
materials sxccpt for tho3e items exempted by statute or rule. A committee hung this Statement for purposes of using the ahortcr'paid for byt and who hove not crossed
the $750 shall notify the Board that the $750 threshold will not be crossed .

4. That Iowa Code section 68A.503 end rules 351-4 .44 through 4 .52 prohloil the receipt of corporate contributions by alt Committees except roc stall and local Dal lot
lxue PACt .

5. A candidate and a randtdtlte's rlxnmittee may only $)Vend campaign funds as pemtined by Iowa code sections 88A.301 through 9aA,303 and rule 951-4,25 .
all
e. That the committee will continue to file disclosure repcf Until activity has Ceased, Committee funds spent, debts resolved, and a final report and a statement of
dissolution (DR3) has been Flea .