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FOR I NSTRUCTI ONS, SEE BACKOF FORM

DI SCLOSURE SUMMARY PAGE

COMMI TTEE NAME ( t i f u

b e s a

s o

S t a t e

t o f Or g a n i z a t i o n ) .

b a e b 4 e

r

C. r

VI MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y o u a r e r e p o r t i n g f o r :

( t

a t e w i d e / L e g i s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e

( 5 ) C o u n t y PAC ( 6 ) B a l l o t I s s u e / F r a n c h i s e Co mmi t t e e ( 7 ) C o u n t y / C i t y C e n t r a l C o mmi t t e e( 6 ) S u p p o r t y5 l a j e o f C a n d i d a t e s

SI GNA UR

TREASURER ( o r p e r s o n f i l i n g t h i s r e p o r t )

I AM F I L I NG A

( r e p o r t d a t e )

FI CHECK I F AMENDMENT TO REPORT DATED

_. s3- zE77

TELEPHONE

Ro u t i n e Pe na l t i e s Du e Fo r L a t e F i l e d Re p o r t s Rang e f r o m $ 2 0 t

SEE I NSTRUCTI ONS ON BACKAND COMPLETE THE FOL LOWI NG SENTENCE :

REPORT FOR AN/ A ( 1 ) ELECTI ON / ( 2 ) N

)

( ] C h e c k i f t h i s i s f i n a l ( t e r m i n a t i o n ) r e p o r t a n d a t t a c h No t i c e o f D i s s o l u t i o n F o r m DR- 3 .

( Yo u mus t c on t i n ue t o f i l e r e p o r t s u n t i l a No t i c e o f D i s s o l u t i o n i s f i l e d . )

ST ATEMENT OF CASH ON HAND

I n d i c a t e o n e

CASH ON HAND a t t h e b eg i n ni n g o f t h e r e p o r t i n g p e r i o d . ( T h i s i s t h e t o t a l

o f a l l mo n i e s h e l d b y t h e c o mmi t t e e . T h i s am o u n t MUST b e t h e

s ame a s t h e c a sh o n h a n d a t t h e e n d o f t h e l a s t r e p o r t i n g p e r i o d ,

o r mus t b e z e r o i f t h i s i s f i r s t r e p o r t f i l e d . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

FORM

DR- 2( Re v . 0 1 / 9 8 )

DI SCLOSURE

REPORT

F o r O f f i c e Us e On l y

Comm . a _

I n d e x

A u d i t e d

Compu t e r

As C~

NOV

4 2 0 0 4

QMI d 2&;

I ON YEAR .

L o c a l C o mmi t t e e s , e n t e r Da t e o f E l e c t i o n

/ UOJ

Z 4 z o o

Co u n t y & L o c a l C o mmi t t e e s , e n t e r Co u n t y i n

wh i c h E l e c t i o n i s h e l d

7 - 7 SS



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

CONTRI BUTI ONS - - MONEYTAKEN I N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )

COMMI TTEE NAME ( M u s t b e s ame a s o n S t a t e m n t o f O r g a n i z a t i o n )

STATE CANDI DATES - N O T E : I F A C ON T R I B U T I O N I S R E C E I V E D FROMA S T A T E P A C ( P O L I T I C A L A C T I O N C OMMI T T E E) , L I S T T H E P A C I D E NT I F I C A T I O NNUMBER A N D T H E P A C CHECK NUMBER I N T H E D E S I G N A T E D COLUMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM T HE I O WA E T H I C S A ND C A MP A I G ND I S C L O SU R E BOARD

CAUTI ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o w a C o d e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e m e n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c o mme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

SCHEDULE

A MONETARY( R e v . 0 6 / 9 7 ) RECEI PTS

CHECK T H I S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AN D ADDRESS OF CONTRI BUTOR R EL A T I ON SH I P AMOUNT 4 I F FORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-

( MM/ D D / Y R ) AN D PAC CHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOME

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Fo r I n s t 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 g c a n d i d a t e ' s p e r s o n a l f u n d s )

COMMI TT EE NAME ( M u s t be s ame a s o n St a t g n j e n t o f Or g a n i z a t i o n)

STATE CANDI DATES NOTE : I F ACONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I CA L ACTI ON COMMI TTEE) , L I S T THE PAC I DENT I F I CATI ONNUMBER ANDTHE PACCHECKNUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S A VA I L A B L E F ROM T HE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .

CAUTI ON : Se c t i o n 68B. 3 2 A ( 6 ) , I o wa C o d e , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c op i e d f r o m r e por t s a n d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c omme r c i a l p ur p o s e b y an y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

SCHEDULE

A MONETARY

( Re v . 0 6 / 9 7 ) RECEI PTS

CHECK T HI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT J I F FORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-

( MM/ DD/ Y R) AND PAC CHECK ( i f a p p l i c a b l e ) R AI S E RNUMBER I NCOME

I D# `

/09 CK# = 3 , f ' 35 Fo . . wr ~ t e P ~OLJv

S , l s t t o ~I D#

CK#l o t s - 00

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( o L ~/ ~CK#

C -XL7t G 5v , 00y

S , c , C i . 6 ~ - St ( d ~I D# t '

CK#

I D#

CK#

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FOR I NSTRUCTI ONS, SEEBACK OF FORM R e s e t F o r m SCHEDULE

EXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT

( Re v . 0 9 / 9 7 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FORCONTRI BUTI ONSMADE TO STATEWI DEOR LEGI SLATI V ECANDI DATES, L I ST THE CANDI DATE I DENT I F I CATI ON NUMBER I N THE DESI GNATED COLUMN ANDTHE 0 CHECK THI S BOXI FPAC CHECKNUMBER FOR EACH EXPENDI TURE A L I ST OF I D NUMBERS I S AVA I LABLE FROM THE I OWA AMENDI NG FORMETHI CS &CAMPAI GN DI SCLOSURE BOARD.

COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t eme n t o f O r g a n i z a t i o n )

, / CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

EXPENDED ( i f a p p l i c a b l e ) ( Di s b u r s e me n t ) WASMADE

( MM/ DD/ YR) AND PAC

CHECK

NUMBER

I D # 7-7. t o 3 , 7 s b , w a , + ^ Zz , n r b , ; :

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FOR I NSTRUCTI ONS, SEE BACK OF FORM

COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e m

t o f O r g a n i z a t i o n )

11 1 e

SCHEDULE

E

I N K I ND

( Re v . 0 6 1 9 7 )

CONTRI BUTI ONS

CHECK THI S BOX I FAMENDI NG FORM

DATE

RECEI VED

( MMI DDI YR)NAME ANDADDRESS

OF CONTRI BUTOR

RELATI ONSHI P

TO CANDI DATE

* ( i f a p p l i c a b l e )

DESCRI PTI ON

OF I N K I ND

CONTRI BUTI ON

ESTI MATED

FAI R MARKET

VALUE

~ I F FOR

FUND- RAI SER

CONTRI BUTI ON

/

/ O~ 1

s Auc ; r e 5o2w" i3 COG, t i p F

< i C - 4 - 4 , i Oi y Ci L 1 r 3Z - ( E e t t l -

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F 7

F7

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F7F 7



FORI N S T RU CT I ON S , SEEBACK OF FORM

T HI S FORMI S USED BY CANDI DATES' COMMI TTEES ONLY

COMMI TT EE NAME( Mus t b e s a me a s o n St a t e me n t o f O r g a n i z a t i o n )

PART I I - I T EMI Z ED BREAKDOWNOF UNREI MBURSED EXPENSES P AI D BY CONSULTANT

TO OTHERS I N PERFORMI NG SERVI CES OF CONTRACT ( T h es e e x p e n s e s s h ou l d NOT be

PART I - NAME AND ADDRESS OF CONSULT ANT

r e p o r t e d o n Sc h e d u l e B, as t h e y ar e d i r e c t p a y me n t f r o m t h e c o n s ul t a n t . )

Name o f Co n s u l t a n t

J_acvhMa i l i n g Ad d r e s s

' 0c i t y

ESTI MATES OF PERFORMANCE

St a t e

Zi p C o d e

TOTAL A NT I C I P A T ED

COMPENSAT I ON FOR

CONTRACT PERI OD ( MMI D DI Y R)

PERFORMANCE

P a g e o f

( f o r S c h ed u l e G)

SCHEDULE

G BREAKDOWN

OF MONETARY( Re v . 0 2 / 9 6 ) EXPENDI TURES

BY CONSULT ANT

QCHECKTHI SBOXI F

AMENDINGFORM

r S L ' ,UU-~CJ

- 4 e 1 2 ' °e _ o e

DATE

EXPENDED( MMI DD/ YR

NAME AND ADDRESS TOWHOMEXPENDI TURE

Di s b u r s e me n t ) WASMADE PURPOSE

AMOUNT

EXPENDED

s

SUB- TOTAL

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

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