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rUr l 1 1 \ 4 , 2 ) 1 MUUI I UI VJ, JCt bAUKOF F - UHr v lCHECKONE:91 , T hi s i s a n i n i t i a l * St a t emen t o f Or g an i z a t i o nQ T hi s i s a n amend ed * St a t emen t o f Or g an i z at i o n' An i n i t i a l S t a t e me n t o f O r g a n i z a t i o n s h ou l d b e f i l e d w i d e n 1 0 d a y s o f t h e c o mm i t t e e ' s ac c o p f ngc o n t r i b u t i o n s . ma k i n g e x p e n d i t u r e s o r i n c u r r i n g i n d e b t e d n e s s e x c e e d i n g , $ 5 0 0 . Ame n d i ne n f s 4 h ou l d b e f i l e dw i t h i n 3 0 d a y s o f a c h a n g e . P e n a l t i e s may b e i mp o s e d f o r l a t e - ( f l e d S t a t e f t f e n ? s o f O r g a n i z a t i o n .

COMMI TTEE NAME ( Re q u i r e d b y l a w)

COMMI TTEE TREASURER ( T hi s ad d r e s s u s e d f o r a d r e m i n d e r s( Re q u i r e d b l aw and c o r n e n c e

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4

DI S POS I T I ON OF BALANCE OF FUNDS UPON DI S SOLUT I ONI n d i c a t e d i s p o s i t i o n o f f u n ds b y me r l o na a p p r o p r i a t e n umb e r i n b o o c~ _ _( 1 ) DONATEDTO COUNTY CENTRAL . COMhQTTEE

( 2 ) DONATEDTO LOCAUSTATE I NAT ' L POL I T I CAL PARTY ( w dw l n s o n e )( 3 ) DONATEDTOCHARI TABLE ORGANI ZAT I ON( s p e c i f y )( 4 ) CI TY / COUNTY I SCHOOL / S TATE OF I OWA GENERAL FUND ( u i d s r w+ s o r e s )( 5) PART I SAN CONGRESSI ONAL DI S TRI CT FUND

FORMDR- 1

Da t e S i g ne dZ - - 98

S i g na t u r e o f Ca nd i d a t e o r Ch ai r p e r s o n ( i f a PAC) Da t e S i g ne d

I MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y ou a r e r e p or t i ng f o r :( 1 ) S t a t e wi d e / L e gi a l a t l v e Ca nd i d a t e (2 ) S t a t e wi d e PAC ( 3 ) S t a v e Pa r t y ( 4 ) Co u nt y / L oc a i Ca nd i d a t e ( S ) Co u n t y PACE" a l l o t l s s u e / F r anc h i s eCo mmi t t e e ( 7 ) Co u nt y / Ci t y Ce n t r a l Commi t t e e ( 8 ) S u pp o r t s l a t e o f c a nd i d at e s ( l i s t c a nd i d at e s u n d e r p u r p o s e o f c on" t t es )C) GO -

COMMI TTEE CHAI R ( L i s t a d d i t i o n a l o f l c e r s o n s e p a r a t e p a g e )

( S t a t e m e n t o f i n t e n t r e q u i r e d t r y l a w f o r a l l c o mmi t t e e s , e x c e p t s t a t e p a r t i e san d c e n t r a l c o mmi t t e e s . )( 8 ) PRORATED REFUNDTO CONTRI BUTORS( 7 ) TRANSFER TO ANOTHERCOMMI TTEE OF THI S SAME CANDI DATE

( CANDI DATES ONLY)( 8 ) RETURN TO PARENT ENT I TY GENERAL FUND ( PACs ONLY)( 9 ) OTHER( PACs ONLY) , PLEASE BE SPECI F I C

STATEMENT OF AFFI RMATI ON BY TREASURERANDCANDI DATE ; OR POLI TI CAL COMMI TTEES, BY CHAI RPERSON1 am a wa r e t h a t I am r e o i r i r o d t o r i l e d i a d o s ws r e p o m i f f t c o n r r r l t e e t e c a i r m c o n Mb u d o ns , me t e s e a p e n d i l u r e s , o r i n c on i n d e b t e d n e s s i n e x c e s s dr i v e h u nd r e d d o l l aa c a l e n d a r y e a r f o r t h e p u r p o s e o f s u p p o r t i n g o r o p p o s i n g an y c and f t t e f o r p u bl e o r e o r b a l l o t i s s u e . I amabo a wa r e t h a t l a t e ~ r e p o r t s a r e s u b j e c t t o c i v i l pe" Nes( f i n e s ) u n d e r t h e d i s d o s u r e l aw. / a l s o u n d e r s t a nd Ma t aNr o u g h t h e t ma w nw n or ma l y p r e p a r e s an d I d e s r e p o r t s . t h e c a n d i d a t e o r d wr p e r s o n ( PACs) i s r e s p o ns e u n d e rl aw f q r a c c u r a t e an d d me / y d i s d os u r e r e p o r t s . F ma r y , I a f f i r m t h a t a l l c o mmi t t e e o f f i c e r s h av e b e e n i n f o r m e d o f t h e i r a p p o i n t me n t an d o b l g a t i o n s .

Name NameW , ' .~- l ' L. -- -` ~~~-

Mai l i ng Ad d r e s s Mai l i ng Ad d r e s s

C i t y , S t a t e Zi p Code C i t y , S t a t e a p Co d ec~ ~ - vo l U &J " - ,Home Phone ( 5 / H Home PhoneDay Phone Da PhonePACs : I NDI CATE PURPOSE OF COMMI TTEEAl l Ca nd i d a t e s En tp i e c e s o u g ht : 4 4 4 - &k - ~ A D i s t r i c tP o l i t i c a l Pa r t y ( B a p oc a b l e ) . ~ t ! f t u o C' l Ye a r S t a n di n g f o r EI : 1 1 7 9Co u nt y / L v-Ca nd i d a t e s a n d L o c a l Bai t o t f Fr a nc h ) s e Ct xnmi Wes En t e r :Co u n t y : vr Da t e o f E l e c t i o n :Ban k Ac c o u n t Name J Ca nd i d a t e Name r l < Add r e s s o r P ar e n t Ent i t y ( PACs. i f a Wl c a b l e ) .

A f f i l i a t e , o r Sponso r0 - o r v J ~Name o f Fma n c i a l I ns d t u f ) o r V Ty p e o f A c c o u n t Ma i l i n g Ad d r e s s5 ~ - a w e , ( 3 0 - t ~. , r. ~it ~ . , r. ~i - ` r

- `rLL S4- C- , , . Ci ~ e - c w 7

Mai l i ng Ad d r e s s J Ci t y S t a t e Zi pRc 1 3 , oX 3 - - - / V e - - Va. . d ez~Ci t y s t a t e Zi p Home Phone ( 5 1 5 ) ' 4 c g

Day Phone ( 5 1 - 1 3 ! ? ,P-