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11/23/2005 11 :06 1-563-568-6247 WAUKON STATE BANK PAGE 01

For, DR-OTC
CS AND CAMPAIGN DISCLOSURE BOARD
610 EAST 12TH , SUITE 1A ONE-TIME CONTRIBUTION IN
EXCESS Of 376o BY A
DES MOINES, IA 60319 PERMANENT ORGANIZATION
Fax: (515)281-3701
www.lowa.gov/sthit s For office use oniv
Indexed
E CONTRIBUTION
IN EXCESS OF $750 Audited
BY A PERMANENT ORGANIZATION Checked
Computer
a
Iowa Code section 68A.402(g) requires permanent organization that contributes in excess of
$750 to register and file reports as a PAC. This form is intended to serve those purposes . to
form must by filed wi h the Board on or before the to day of the date the check was issued
ORGANIZATION MAKING CONTRIBUTION :I

Veterans Manorial Hospital Foundation


Name
40 1st Street SE, Waukon, IA 5 2172
Mailing Address City . State. Zip Code

admin@vmhospital-corn 563-568-3411
Email Address (Optional) - - Area Code & Telephone No.

CONTACT PERSON FOR THE ORGANIZATION:

Sand ra- DE!al_


Nam040 1st Street SE, Waukon, IA 52172
Mailing Address City, State, ZIP
admin@vrnhospital .coal 563-568-3_41_1
Email Address (Optional) Area Code & Telephone Number

CANDIDATE OR COMMITTEE REC EIVING THE CONTRIBUTION :

Allamakee Pride Calmittee


Name of Candidate or Committee
PO Box 9, Waukon, IA 52172
Mailing Address City, Stata, Zip Code
10-14-05 2,250 .00
Date of Contribution Amount
gait@waukonstatebank .com 563-568-34 51
Email Address (if available) Area Code & Telephone Number
12-13-05 Allamakee
Date of Election County (If Applicable)
none
If contribution to candidate, disdose source of original funds used to make
such contribution (attach additional pages If necessary) . If In-Kind Contribution, Describe

Criteria to use this form :

One campaign contribution In excess of 5750 was made to a stale or local candidate, party, political committee (PAC) for either a
candidate or a ballot issue. or any other organization that advocates the election or defeat of a candidate or ballot issue.
2. Must be a permanent organization not established for election purposes .
3, No person gave money to the organization for the purpose of the organization then using the money to make the contribution.
a. If the contribution was made to a candidate, no funds from a corporation or other prohibited contributor under Iowa Code section
68A_503 were used to make the contribution (this does not apply to a contribution made to a ballot issue committee) .
5. Only one contribution to any campaign committee except for
a ballot Issue committee was made in a calendar year . No more than one
contribution may be made to any one ballot issue committee during a ballot Issue election . If more than one contribution and the total
amount of the contributions exceed $750, the organization must register with the Board as a political committee (PAC) within 10 days of
crossina the $750 threshold,

Statementof Affirmation:
i, Gail PreSten'On aMnr, that the contribution reported above Is accurate . I further aMnn that the Information concerning the organization is
correct end true to the best of my knowledge. I understand that by filing this form, 1 am subject to the laws found In Iowa Coda chapter 68A and
administrative rules found in chapter 351 . I also understand thst the (allure to timely file this forth leads to the Imposition ofcivil
penalties and the
intentional future to 111e the forge may lead to additionalcivil and criminal sanctions .

November 23, 2005


Date

"Contribution" Includes goods or services that are provided for free or otherwise less than fair market value.