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FOR INSTRUCTIONS,

SEE BACK OF TONNI€


ln rTrrrltF re'l'lil
CbIECKONE: ' "
rniti"r Statement of Organization II I ' . ':'1
Elii"ir
"n amEnded*Statementof Organization
fnis is an
'AnEinitiatStatementof OrganEationmustbe fileclwithin10daysof the@ffWqf1AH {P&pfiffioftiffine Gomm.#
makingexpenditurcs, or incuningindeDtedness exceeding9750.Anen&ildfti lhhbtEe-filed'ivith-n 30 daysof lndexed
a change.Penalties maybelmposed for lat*filedStatementsof Organization.A canclidatewithan open Audited
committee thatexceeds officeshallfilewithin10clayseithera newor amended
$750in activityfor another
DR-l disclostng informationconceming thecampaign forthenewofficesought.
J J tn candidate's lasl namein lhe nameof the committee.)
commitleemustincludEthe candidate's

type of commltteoyou arc reporflngfon


(l )Statewlde/LeglslatlvelJudgeStandlngforRetenUonGandldate (2)StatewldePAC(3)SbteParty (4lcountyCentnlGommlttee
(5)CountyCandldate (6)CltyGandldatE (7)SchoolBoadorOtherPollficalSubdlvlslonCandldate (8)CountyPAC(9)CltyPAC
l0 )SchoolBoardor OtherPoliticalSubdlvlsionPAC ( lt ) Local Ballot lssue

COMMITIEECHAIR

City,State J J Zip Code J J

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(lf activein multipleballotissueelections,attachlistof counties

Dateof Election:

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Uwfux,f
of Account
of FinancialInstitution/type
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ciry J + srateJ I zip J J

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STATEMENTOF AFFIRMATON: By flllng thle documentthe commlttEeafflrms the followlng:

L The committeeand all persons connectedwith the commnee understandthat they are subject to the laws In lowa Code chapters 68A and 688 and the admlnlsbative
rulesin Chapter351 of the lowaAdmlnlstrattue
Code.
2. That lowa Code section68A.402and rule 351-4.9 requirethe fillngof disclosurereportsand that the fallureto file these repoftson or bebre the requlreddue dates
subjecG the candidateor chalrpenon (ln the case of commifteesother than a candldate'scommlttee)to the automaticassessmentof a civll penalty and the posslble
lmpositlonof othercrimlnaland civil sanctions.
3. That lowa Code sectlon684.405and rules351-4.38 through4.43 requirethe placemenlof the words"paldfor byr and lhe nameof the commftteeon all polifical
malerials exceptfor those ltems exempted by statute or rule, A commlfteethat wishes to reglstera commlttee name for purposesof uslng the shorter "pald br by'"and
does not Intendto crossthe $750fillngthresholdshallfile the FormDR-SFAform in lieu of tllng this form.
4. Thai lowa Code sec{ion68A.503and rules 351-4.44 through4.52 prohibitthe recelpt of corporatecontributlonsby all commltteesexcept for statewideand local ballot
issue PACs.
5. A candldateand a candldate'scommltteemay only expendcampalgntundsas permmedby lowa code secllons68A.301through68A.303and rule 3514.25.
6. That the commttteewlll contnue tg file disclosurereports until all activity has ceased, commifieefunds spent, debts resolvd, and a final reporl and a statemenl of
dissofuton (DR<IIhas neen frled/'

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DatoSlgnod

Slgnatureot Candldato,OR,lor all othorcommitlees,Chalrpereon Data Slgned