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FOR I NSTRUCTI ONS, SEE aACK OF FORM

DI SCLOSURESUMMARY PAGECO E NAME ( Mu b e same a s o nS t a t e me n to fO r g a n i z a t i t ~ r r )

I MPORTANT: I n d i c a t et y p eo fc o mmi t t a oy s aa r er e p e r d n gf o r.

( 1) S t a t e w i d e / L e g i s l a t i v eC an d i d a t e(2 ) S t a t e w i d ePAC( 3 ) S t a t eP a r t y(4 ) C o u nt y i L o c W C a nd i d a t e(5 ) C o u n t yPAC (6 ) B a l l o tI s s u e F r a n d i i s eC ommi t t e e( 7 ) C o u n t y / C i t yC e n t r a lC ommi t t e e( 8) S u p N o r tS l a t eo fC an d i d a t e sCANDI DATECOMMI TTEESONLY :

FORM

DR- 2( R e v. 0 7 1 2 0 0 3 )

DI SCLOSUREREPORT

F o rO f f i c eUs*On l y~~Comm. #L o g g e dS c a n n e d

OCT 2 8 : 2004J

m ( 0 - ~ - 7

SI GNATUREO TREASURER ( o rp e r s on 11111g t h i s r e p o r t )

U Check i ft h i si s f i n a l( t e r mi n at i o n )r e p o r ta n d a t t a c hN o t i c eo fD i s s o l u t i o nF or mDR- 3.( Yo u mu s tc o n t i n u et o f i l er e p o r t su n t i la No t i c e o fD i s s o l u t i o ni s f i l e d. )

_

3 y . zTEL EPHONE DATE SI GNED

La t e f l e d r e p or t sa r e s u bj e c t t o p os s i b l ec i v i la n d c r i mi n a l p e n a l t i e s.

SEE I NSTRUCTI ONS N BACK AND COMPL ETE THE FOLL OWI NGSENTENCE :I AM F I L I NGA 69F~ j ~ I r r ' ~ x . 9 '. m REPORT FOR AN/ A( 1 )ELECTI ON l ( 2 ) NOWELECTI ONYEAR.

( r e p o r td a t e )I n d i c a t eon e L / J

[ ] CHECK I FAMENDMENT TO REPORT DATED

STATEMENT OF CASH ON HAND

CASH ON HAND a t t h eb e g i n n i n go ft h er e p o r t i n gp e r i o d. ( T h i si s t h et o t a lo fa l lmon i e sh e l d

b y t h ec o mmi t t e e. T h i samountMUST b e t h esame a s t h ec a s ho n h an da t t h ee n do f t h el a s tr e po r t i n g p er i o d ,o rmust b e z e r oi ft h i sI sf i r s tr e p o r tf i l e d. ) . . . .. . . . .. . .. . . . .. . . . .. . .. .. . . . . .$

ADD TOTALMONEY TAKEN I NTHI SPERI ODSc h e d u l eA: Cash C o n t r i b u t i o n st o t a l( A t t a c hS c h e d u l eA) ( ' a l s os e e i n - k i n db e l o w). .. . . . .. ..

Sc h e d u l eF : Loan s Re c e i v e dt o t a l( A t t a c hS c h e d u l eF ). .. .. . . .. . . . .. . .. . .. . . . . . . . . .. . .. . .. .. . . . . .. .. .. . . . .. . .

Sc h e d u l eH : To t a lSa l e so fCampa i gnP r o p e r t y ( A t t a c hS c h e d u l eH) . .. . .. . . . .. . .. . . . .. . . . . . . . . .. . . . ..

( Sc h e du l eH a p p l i e st o C an d i d a t e s 'Commi t t e e sOn h f l

SUB- TOTAL.. . . .$

SUBTRACT TOTAL MONEY SPENT THI SPERI OD

S c h e d u l eB: E xp e nd i t u r e st o t a l( A t t a c hS c h e d u l eB ) ( " a l s os e e d e b t san d l o a n sb e l o w).. . .

S c h e d u l eF : L oa n Re p a yme n t st o t a l( A t t a c hS c h e d u l eF ).. . .. . .. . .. . .. .. . .. .. . .. ... .. . .. .. ... . . . .. . .. .. . .. ..

CASH ON HAND a t t h ee n do ft h i sr e p o r t i n gp e r i o d( i ff i n a lr e p o r t ,b a l a n c emustb e z e r o )( A t t a c hDR- 3 ). .. . . . . .. .. .. .. . . .. . . . .. . .. . . . .. .. . .. . .. .. . .. . . . .. . .. . . . . . . .. . . . .. ... .. .. . . .. . .. .. . .. . . . .. . .. .. . . . .. . .. . ..$

" UNPAI DBI LLS( F r o mSc h e d u l eD - A t t a c hSc h e du l e D). . .. . . . . . . .. . . . . . . .. . . .. .. . .. .. . .. . . . .. . .. . . . .. . .. . .. .. .. . . . . . . ..$

` "N KI NDCONTRI BUTI ONS( F r o mS c h ed u l eE - A t t a c hS c h e d u l eE ) .. . . . . .. . . . . . . .. . . . . . . .. . . . .. . . . . . . .. .. . . . . . . ..$" OUTSTANDI NGLOANS ( F r o mSc h e d u l eF - A t t a c hSc h e d ul eF ). .. ... . .. . .. . .. . . . .. . . . . . . .. . . . .. . . . .. . .. .. .. . .. . ..$CANDI DATE COMMI TTEESONLY :

CONSULTANT BREAKDOWN ( S c h e d u l eG A t t a c h e d ? )

VALUE OF CAMPAI GNPROPERTY ( F r o mS c h e d u l eH - A t t a c hS c h ed u l eH) $

/ L ` . - ; - 17 - U

L o c a lC ommi t t e e s ,e n t e rD a t eo fE l e c t i o n

C o u n t y&L o c a lC o r n r r m f e s ,e n t e rC o u n t yi nwh i c hE l e c t i o ni sh e l d

A / " ,F ~1 ,

7? ?4,

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CONTRI BUTI ONS - MONEY TAKEN I N( I n c l u d i n gc a n d i d a t e ' sp e r s o n a lf u n d s )

COMMI NAME ( Mu s t b e s a me a s o n St a t e me n t o f Or g a ni z at i o n)

~sCI f

- Re s e t Fo r m

TOTAL ( i fl a s t page o f t h i s s c h e du l e )

SCHEDULE

A MONETARY( Rev . 0 7 / 0 3 ) I RECEI PTS

0 CHECK THI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE_ I FA CONTRI BUTI ONI SRECEI VEDFROM A STATE PAC ( POL I T I CALACTI ONCOMMI TTEE). L I STTHEPAC I DENTI F I CATI ONNUMBER AND THE PAC CHECK NUMBER I NTHE DESI GNATEDCOLUMN . A L I STOF I DNUMBERS I SAVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GNDI SCL OSUREBOARD

CAUTI ON : Se c t i o n 6 8B . 3 2 A ( 6 ) ,I o wa Code , p r o h i b i t st h e u s e o f i n f o r mat i o nc o pi e d f r o mr e por t s and s t a t e me n t s f o r s o l i c i t i n gc on t r i b ut i o nsf o rany c omme r c i a l p u r p o s e b y any p e r s o n o t h e r t h an s t a t u t o r yp o l i t i c a lc o mmi t t e es .

Di s c l o s u r el aw r e q u i r e sc a nd i d a t ec ommi t t e es t o d i s c l o s et h er e l a t i o n s h i po f an y r e l a t i v ema k i r x fa c o n t r i b u t i o nt o t h ec ommi t t e e. R e l a t i o n s h i pmus t b e s h o w n t o t h et h i r dd e g r e e o f c o n s a n gu i n i t y ( b l o o dr e l a t i v e s )a n d a f f i n i t y( r e l a t i v e sb yma r r i a g e ). I fs u r n a me o f c o n t r i b u t o ri s t h es ame as c an di d a t e , b u t t h e r ei s n of a mi l i a lr e l a t i o n s h i D. e n t e r" n o ta p p l i c a b l e "i n t h er e l a t i o n s h i pc o l u mn. ( f o rSc h e d u l e A)

P a g e - o Z _ _ o f _ K _ _ _

DATERECEI VED

PAC I DNUMBER( i fa pp l i c a b l e )

NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT I FF

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Fo r I n s t r u c t i o n s ,Se e Back o f F o r m

CONTRI BUTI ONS - MONEY TAKEN I N( I n c l u d i n gc a nd i d a t e ' sp e r s o n a l f u n d s )

COMMI TT NAME ( Mu s t b e s ame as o n St a t e ni e nt o f Or g an i z at i o n )

~SGh d~

R e s e tF or m SCHEDULEA MONETARY

( Re v . 0 7 / 0 3 ) 1 RECEI PTS

CHECK THI SBOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I FA CONTRI BUTI ONI SRECEI VEDFROM A STATE PAC ( POLI T ICALACTI ONCOMMI TTEE) ,L I S TTHEPAC I DENTI F I CATI ONNUMBERAND THE PAC CHECK NUMBER I NTHE DESI GNATEDCOLUMN . A L I STOF I DNUMBERS I SAVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GNDI SCL OSUREBOARD

CAUTI ON: Sec t i o n6 8 B. 3 2 A ( 6 ) ,I o wa Code , p r o h i b i t st h e u s e o fi n f o r mat i o nc o pi e d f r o mr e po r t s a nd s t a t e me n t s f o rs o l i c i t i n gc on t r i b ut i o nsf o ra ny c omme r c i a l p u r p o s eb y a ny p er s o n o t h er t h an s t a t u t o r yp o l i t i c a lc o mmi t t e es.

SUB- TOTAL$. i " Oa

~

TOTAL ( i fl as t p a g e o f t h i ss c h e du l e )

' D i s c l o s u r el awr e q u i r e sc a n di d a t ec ommi t t e e s t od i s c l o s et h er e l a t i o ns hi p o fa n y r e l a t i v emak i ng a c o n t r i b u t i o nt o t h ec ommi t t e e. R e l a t i o n s h i pmus t b e s h o wn t o t h et h i r dd e g r e e o f c o n s a n g u i n i t y( b l o o dr e l a t i v e s )a n d a f f i n i t y( r e l a t i v e sb ym a r r i a g e ). I fs u ma me o f c o n t r i b u t o ri s t h e s ame as c an di d at e , b utt h er e i s n o P a g e o ff a mi l i a lr e l a t i o n s h i p. e nt e r " n o ta p p l i c a b l e 'i n t h e r e l a t i o n s h i pc o l u mn. ( f o rSc h ed u l eA)

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT ~ ' I FFRECEI VED ( i fa pp l i c a b l e ) TO CANDI DATE' RECEI VED FUND( MM/ DD/ YR) AND PAC CHECK ( i fa p p l i c a b l e ) RAINUMBER I NCO

I D#

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Fo r I n st r u c t i o ns , See Back o f Fo r m

CONTRI BUTI ONS - MONEY TAKEN I N( i n c l u d i n gc a n d i d a t e ' sp e r s o n a lf u n d s )

COMMI TT NAME ( Mus t b e s ame a s o n St a t e me n t o f Or g a ni z a t i o n)

~s Ch d~ e-

- R e s e t ,

Fo r m SCHEDULE

( Re v.A MONETARY0 7 / 0 3 ) RECEI PTS

CHECK THI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I FA CONTRI BUTI ONI SRECEI VEDFROM A STATE PAC ( POL I T ICALACTI ONCOMMI TTEE). L I S TTHE PAC I DENTI F I CATI ONNUMBER AND THE PAC CHECK NUMBER I NTHE DESI GNATEDCOLUMN . A L I S TOF I DNUMBERS I SAVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GN

DI SCL OSUREBOARD

CAUTI ON : Se c t i o n 68B . 3 2 A( 6 ). I o wa Cod e, p r o h i b i t st h e u s e o f i n f o r mat i o nc op i e d f r o mr e p o r t s an d s t a t e me nt s f o rs o l i c i t i n gc on t r i b ut i o nsf o ran y commer c i a l p u r p o s e by an y p e r s o n ot h er t h an s t a t u t o r yp o l i t i c a lc o mmi t t e e s .

SUB- TOTAL

TOTAL ( f fl a s tp ag e o f t h i ss c h e du l e )

' Di s c l o s u r el a wr e q u i r e sc a n di d a t ecommi t t e e s t od i s c l o s et h er e l a t i o n s h i po f a n y r e l a t i v emak i n g a c o n t r i b u t i o nt o t h ec ommi t t e e . Re l a t i o n s hi pmust b e s h o wn t o t h e t h i r dd e g r e e o f c o n s a n g u i n i t y( b l o o dr e l a t i v e s )and a f f i n i t y( r e l a t i v e sb yma r r i a g e ). I f s u r n ame o f c o n t r i b u t o ri s t h e same as c an di d a t e , b u t t h e r ei sn of a mi l i a lr e l a t i o n s h i D. e n t e r " n o ta p p l i c a b l e "i n t h e r e l a t i o n s h i pc o l umn. ( f o rSc h e d ul e A)

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT v I FFRECEI VED ( i fa p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND( MM1DDl YR) AND PAC CHECK ( i fa pp l i c a b l e ) RAI S

NUMBER I NCOME

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CONTRI BUTI ONS - MONEY TAKEN I N( I n c l u d i n gc a n d i d a t e ' s p e r s o n a lf u n d s )

COMMI NAME ( Mu s t be s ame a s on St a t e me n t o f Or g an i z a t i o n)

~s Gh

Re s e t Fo r m SCHEDULE

A MONETARY( Rev . 0 7 / 0 3 ) I RECEI PTS

CHECK THI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I FA CONTRI BUTI ONI SRECEI VEDFROM A STATE PAC ( POLI T I CALACTI ONCOMMI TT EE). L I S TTHEPAC I DENTI F I CATI ONNUMBERAND THE PAC CHECK NUMBER I NTHE DESI GNATEDCOLUMN . A L I S TOF 1 0NUMBERS I SAVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GNDI SCLOSUREBOARC

CAUTI ON : Se ct i o n 68B . 3 2 A ( 6 ) ,I o wa Code, p r o h i b i t st h e u s e o f i n f o r mat i o nc o p i e d f r o mr e p o r t s an d s t a t e me n t s f o rs o l i c i t i n gc on t r i b ut i o nsf o ran y c omme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h an s t a t u t o r yp o l i t i c a lc o mmi t t e e s .

SUB- TOTAL

TOTAL ( i fl a st page o f t h i s s c h ed u l e )

' Di s c l o s u r el awr e q u i r e sc a nd i d a t ec ommi t t e e s t o d i s c l o s et h er e l a t i o n s h i po f any r e l a t i v emak i ng a c o n t r i b u t i o nt o t h ec ommi t t e e. R e l a t i o n s h i pmus t b e s h own t o t h et h i r dd e g r e e o f c o n s a n gu i n i t y ( b l o o dr e l a t i v e s )a n d a f f i n i t y( r e l a t i v e sb yma r r i a g e ). I fs u r n a me o f c o n t r i b u t o ri s t h es ame a s c an di d at e , b utt h e r e i s nof a mi l i a lr e l a t i o n s h i p. e n t e r" n o ta p p l i c a b l e 'i n t h er e l a t i o n s h i pc o l u mn . v ( f o rSc h e d u l e A)

DATERECEI VED

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NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT I FF

( MM/ DD/ YR) AND PAC CHECKTO CANDI DATE'

( i fa p p l i c a b l e )RECEI VED FUND

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I NCOID#

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CONTRI BUTI ONS - MONEY TAKEN I N( I n c l u d i n gc a n d i d a t e ' s p e r s o n a lf u n d s )

COMMI NAME ( Mu s t be s ame a s o n St a t eme n t o f Or g an i z at i on )

Re s e t Fo r mSCHEDULE

A MONETARY( Re v . 0 7 / 0 3 ) I RECEI PTS

Q CHECK T HI SBOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I FA CONTRI BUTI ONI SRECEI VEDFROM A STATE PAC ( POL I T I CALACTI ONCOMMI TTEE). L I S TTHE PAC I DENTI F I CATI ONNUMBER AND THEPAC CHECK NUMBER I NTHE DESI GNATEDCOLUMN . A L I S TOF I DNUMBERS I SAVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GN

DI SCL OSUREBOARD

CAUTI ON : Se c t i o n 6 8B . 3 2 A( 6 ). I o wa Code . p r o h i b i t st h e u s e o f i n f o r mat i onc o pi e d f r o m r e p or t s and s t a t e me nt s f o rs o l i c i t i n gc on t r i b ut i on so rf o rany c o mme r c i a l p u r p o s e b y any p e r s o n o t h e r t h an s t a t u t o r yp o l i t i c a lc o mmi t t e es.

U

SUB- TOTAL

TOTAL ( i fl as t p a g e o f t h i s s c h ed u l e )

' Di s c l o s u r el a wr e q u i r e sc a n di d a t ec ommi t t e est o d i s c l o s et h er e l a t i o n s h i p o fan y r e l a t i v ema k i n ga c o n t r i b u t i o nt o t h ec o mmi t t e e. Re l a t i o n sh i pmus t b e s h ow n t o t h et h i r dd e g r e e o f c o n s a n gu i n i t y( b l o odr e l a t i v e s )an d a f f i n i t y( r e l a t i v e sb yma r r i a g e ). I f s u ma me o f c o n t r i b u t o ri s t h e s ame as c an di d at e , b utt h er e i sn o P a g e - _?off a mi l i a lr e l a t i o n s h i p ,e nt e r ' n o ta p p l i c a b l e "i n t h er e l a t i o n s h i pc o l u mn. ( f o rSc h e d u l e A)

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT I FFRECEI VED ( i fa p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-( MM/ DD/ YR) AND PAC CHECK ( i fa p p l i c a b l e ) RAI

NUMBER I NCOMID# 77 7 77 77

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TOTAL ( f fl a st p age o f t h i s s c he du l e )

A MONETARY( Rev . 0 7 / 0 3 ) RECEI PTS

CHECK THI SBOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I FA CONTRI BUTI ONI SRECEI VEDFROM A STATE PAC ( POLI T I CALACTI ONCOMMI TT EE). L I S TTHE PAC I DENTI F I CATI ONNUMBER AND THE PAC CHECK NUMBER I NTHE DESI GNATEDCOLUMN . A L I S TOF I DNUMBERS I SAVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GN

DI SCL OSUREBOARD

CAUTI ON : Se ct i o n 6 8B . 3 2 A( 6 ). I o wa Code . p r o h i b i t st h e u s e o f i n f o r mat i o nc o pi e d f r o m r e p o r t san d s t a t e me n t s f o r s o l i c i t i n gc on t r i b ut i o nso rf o ran y c omme r c i a l p u r p o s e b y an y p e r s o n o t h e r t h an s t a t u t o r yp o l i t i c a lc o mmi t t e e s .

Di s c l o s u r el a wr e q u i r e sc a n di d a t ec ommi t t e e s t o d i s c l o s et h e r e l a t i o ns hi p o fa n y r e l a t i v emak i n g a c o n t r i b u t i o nt o t h ec ommi t t e e. Re l a t i o ns h i pmust b e s h o wn t o t h e t h i r dd e g r e e o f c o n sa n g ui n i t y( b l o odr e l a t i v e s )a n d a f f i n i t y( r e l a t i v e sb ym a r r i a g e ). I fs u r n ame o f c o nt r i b u t o ri s t h e same a s c a n di d a t e ,b u t t h e r ei sn o P a g e o ff a mi l i a lr e l a t i o ns h i p ,e n t e r " n o ta p p l i c a b l e "i n t h er e l a t i o n s h i pc o l u mn. ( f o rSc h e d ul e A)

DATE PAC I DNUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT I F FRECEI VED ( i fa pp l i c a b l e ) TO CANDI DAT E' RECEI VED FUND( MMl DD/ YR) AND PAC CHECK ( i ta p p l i c a b l e ) RAI S

NUMBER I NCO

161as1 y

ID#

CK#

A , lr -. I e S o - w z -. S G _ TF , SZ mow ; S - a6 v $~~b n '

- ~ , ~ - / 3 a n To

/ x 13/ 0

I D#

CK# mow - s a a. ~ ~ . 3 Cb -0I D#CK# v . l s a ~Sl L E

I D#

~~a51blc

CK# 0 3 ~a

i o r ~~~cI D# ( 0 1 07 5

c K# 3

v A-2

. a l e- fG l aS P'. , ~ -

i v

a 3 337/ i 4 - r - r ;5 ' v Jr i . v e -

ol d4 0 y

I D#( o

C .3 : 3 3 /

c r v

13 0/ I D #p qUl 1 9 6 3I D#

CK#

CK# E : 1

I D#

CK#

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THI S BOX APPLI ES TO CANDI DATES' COMMI TTEES ONLY :

P ur c h a s e so f c e r t a i nc a mp a i g n p r o p e r t y c o s t i n g$ 5 0 0 o r mo r e mu s t a l s ob e i n v e n t o r i e do n Sc h e d u l e H . ( R e f e rt o Sc h e d u l e H i n s t r u c t i o n s. )

E x pe nd i t u r e st o p e r s o n s / e n t i t i e sp r o v i d i n gc o n s u l t i n g ,a dv e r t i s i n g , f u n d - r a i s i n g ,p o l l i n g ,ma n a g i n g , o r g a n i z i n g s e r v i c e smust a l s ob e d e t a i li t e mi z e d o nSc h e d u l e G by t h e amo u n t , p u r p o s e ,a n d d a t eo f e a c h t y p eo f e x p en d i t u r emade b y t h e p e r s o n / e n t i t yo n b e ha l fo f t h e c an di d a t e ' sc o mmi t t e e. ( R e f e rt oSc h e d u l e G i n s t r u c t i o n sa n d I owa Code 6 8A . 6 ( 3 ) ( i ). )

P a g e _ _ _ _ 2 - - - -o f _ _ __ -

( f o rSc h e d u l e B)

FOR I NSTRUCTI ONS,SEE BACK OF FORM I " " l I. SCHEDUL E

EXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT ( Re v . 0 7 / 0 3 ) EXPENDI TURESSTATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONSMADE TO STATEWI DE OR LEGI SLAT I VECANDI DATES,L I S TTHE CANDI DATE I DENT I F I CATI ONNUMBER I NTHE DESI GNATEDCOLUMN AND THE D CHECK THI S BOX I FPAC CHECK NUMBER FOR EACHEXPENDI TURE . A L I STOF I DNUMBERS I SAVAI LABLEFROMTHE I OWA AMENDI NG FORMETHI CS& CAMPAI GN DI SCLOSUREBOARD .

COMMI TTEE NAME ( Mu s tb e s ame a s o n St a t eme n t o f Or g a n i z a t i o n )

CANDI DATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNTDATE I DNUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

EXPENDED ( i fa p p l i c a b l e ) ( Di s b u r s e me n t )WAS MADE( MM/ DD/ YR) AND PAC

CHECKNUMBER

I D# 17 7_777~ l , t: u

CK# $ SOD- _

I D#

CK#7S

I D# - -

r p -. z z - ~ f CK# ~ s~1 , 4

ID#

CK#

I D# -

, , 2 4

- cK#

ID#

C K#

1D#

C K#

1D#

C K#

SUB- TOTAL $

TOTAL ( i fl a s tp a g e o f t h i ss c h e du l e ) $02 0 S~4101 ' t U

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FOR I NSTRUCTI ONS,SE` BACX QF . FORM

l COMMI l l , EE NAME ( Mu s th e s ame " a n St a t e me n to OMa n f mEl t x r )/ a SG ~ - ~o~ Sl p -f ~GK ~ e -

SEHULEE

( Re v. OBI Q 7 y 1CONTRI BUTI ON

p CHECK THI S BOX IAMENDI NG FORM

* DMdOWt a l awt q * a s c wx l d e st od e d o a ema r d r o nf t a f a r r wn n oM a i nwmea c n t r mu r o na t o po p ~ . ~ o f lc a emd e s e. mPAMftmhipu s tb e Mwwn t ot h e t h i r dd o Wwo f c or ng d i l q ( b l o o dr a l s l i w s e )a m a f t * ( n o i s l l w s ( f o rSd r a u r e E)b Yma n l s g e ). ( Se e P a g e 2 a t t i p. . p a c l a e t i )I f s wneme a t c a r A d b u t o ri s t h ea em e a s , a r t t wm i sn ot am m i m l i o r s s k i l p ,e r a s r ` n o ta pp l l r wh WI nt h en d e d b a a t r i pc o h s m .

I A 1 TERECEI VED( MWD/ YR)

NAMEAND ADDRESSOF CONTRI BUTOR

RELATI ONSHI PTO CANDI DATE' ( i fs p p i c a b w)

DESc Fu FnONOF I N KI ND

CONTRI BUTI ON

EST I MATEDFAI RMARKET

VALUE

- 1 I FFORFUND- RA

CONTRI BUTI O

S

~t i l wVt J ~ r