Nov 07 05 11 :56a

FOR INSTRUCTIONS, SEE BACK OF FORM

CHECK ONE: FORM STATEMENT
This is an initial' Statement of Organization [W'il - 7 2005 DR-1 OF
LJ This is an amended' Statement of Organization (REV. 05/2005) ORGANIZATION
"An initial 5taWrlent of Organization must be fled within 10 days of doe cotmrtitee's accepting contributions, For Office Use OniY
making expenditures or incurnlng indebtedness exceedng $750. Amendments must be Mod within 30 days of Corm . #
a change. Penalties may be imposed for la"ed Statements of Organization. A candidate wth an open Indexed
committee that exceeds $750 in acfvty for anodler office shall file within 10 days either a new or amended
Audited
DR-1 disclosing information concerning the campaign for the new office sought.
Commuter

COMMITTEE NAME 1 1

IMPORTANT: Indicate type of committee you are reporting for[-~

(1 )StatewidefLegislative/Judge Standing for Retention Candidate ( 2 )Statewide PAC (3 )State Party (4 )County Central Committee
( 5 )County Candidate ( 6 )City Candidate (7 )School Board or Other Political Subdivision Candidate ( 8 )County PAC ( 9 )City PAC
(10)Schoo( Board or Other Political Subdivision PAC (11 )Local Ballot Issue
COMMITTEE TREASURER (mandatory for all committees) COMMITTEE CHAIR
Name ~
IlQrfv~V~fd
M ailin Address 1 1
l 3'V~( De .
City, State 1 1 Zip Code 1 1
Ot ett.!) W -, ~~ cxr a
Phone (~ SiJ ) G ~~ "' ~~ G

INDICATE PURPOSE OF COMMITTEE - Check One Box

Comment or description :
All Candidates E~ tar.
Office Sought I.RI t'`1
T(Gt{~ L District

Political Party (if applicable) Year Standing for Election: ZC0, f

County/Local Candidates and Local BallotfFranchise Committees Enter
.
County : hZ,4:efrZ Z--f7 Date of Election : Ald2Z25 2

Bank Account Name 1 4 Candidate name & Address or Parent Entity (PACs . if applicable).
1 1 AtFlfate . or Sponsor

514~
Name of Financial InstitudonItype of Account 1 1 Mailing Address 1 1

7-r- E7'-Tw-f-Wdft7 Z-.f-,- a& c.k-

Mailing Address 1 1 Zip
i0o
1-3 o Tr~t~t~lci'A- l~ Sic? l
State 1 1 Zip 1 1
Phone (l;v lf

STATEMENT OF AFFIRMATION- By filing this document the committee arms the following :

1 . The committee and all persons connected with the committee understand that they are subject to the laws in Iowa Code chapters 68A and 688 and the administrative
rules in Chapter 351 of the Iowa Administrative Code .
2 . That Iowa 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 or chairperson (in the case of committees other than a candidate's committee) to the automatic assessment of a civil penalty and the possible
imposition of other oriminal and civil sanctions.
3 . That Iowa Code section 68&405 and rules 351--4.38 through 4 .43 require the plaoernent of the words 'paid for by` and the name of the committee on all political
materials except for arose items exempted by statute or rule. A committee filing this statement for purposes of using the shorter 'paid for by' and who have not crossed
the $750 shall notify the Board that the $750 threshold will not be crossed .
4. That Iowa Code section 68A503 and rules 351-4.44 through 4 .52 prohibit the receipt of corporate contributions by all committees except for statewide and local ballot
issue PACs.
5 . A candidate and a candidate's committee may only eirend campaign funds as permitted by Iowa code sections 6IiA .301 through 68&303 and rule 351-4.25 .
6 . That the committee will continue to file disclosure reports unfit all activity has ceased, committee funds spent, debts resolved, and a final report and a statement of

G
dissolution (DR-3) has been filed,

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/V r:' rJ l 2 U o_,S
Signature a Candidate, OR, for all other committees, Chairperson j Date Signed