Cedar Rapids Physician-Hospital Organization PAC__9694__scanned

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  • 8/7/2019 Cedar Rapids Physician-Hospital Organization PAC__9694__scanned

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    FOR I NSTRUCTI ONS, SEE BACK OF FORMDI SCLOSURE SUMMARY PAGE

    I AM F I L I NG A J u l y 1 9 , 2 0 0 5( r e p o r t d a t e )

    OCHECK I F AMENDMENT TO REPORT DATED

    F 1 Che 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 N o t i c e o f D i s s o l u t i o n F or m DR- 3( Yo u mus t c o n t i n u e t o f i l e r e p o r t s u n t i l a DR- 3 i s f i l e d . )

    COMMI TTEE NAME ( Mu s t b e s am e 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 )

    C e d a r R a p i d s P h y s i c i a n - H o s p i t a l l O r g a n i z a t i o n P o l i t i c a l A c t i o n Commi t t e eI MPORTANT : I n d i c a t e b y # t y p e o f c o mm i t t e e y o u a r e r e p o r t i n g f o r :( 1 ) S t a t e w i d e / L e g i s l a t i v e / J u d g e S t a n d i n g f o r R e t e n t i o n C a n d i d a t e ( 2 ) S t a t e PAC ( 3 ) S t a t e P a r t y( 4 ) C o u n t y C e n t r a l Co mmi t t e e ( 5 ) C o u n t y C a n d i d a t e ( 6 ) C i t y Ca n d + t e ( 7 ) S c h o o l B o a r d o r O t h e rP o l i t i c a l S u b d i v i s i o n C a n d i d a t e ( 8 ) C o u n t y PAC ( 9 - ) C i t y PAC ( 1 0 c h o o l B o a r d o r O t h e r P o l i t i c a lS u b d i v i s i o n PAC ( 1 1 ) L o c a l B a 1 Mt ' 1 S 6 " - -CANDI DATE COMMI TTEES O W.Ca n di d a t e Name a p o l i t i c a l P a r t y ( i f a p p l i c a b l e )J&O f f i c e S o u g h t D i s t r i c t ( i f Se n a t e o r H o u s e )

    515 283- 180SI GNATURE F PERSON F I L I NG REPORT TELEPHONE

    REPORT FOR ( 1 ) ELECTI ON / ( 2 ) NON- E L ECT I ON YEAR .I n d i c a t e b y #

    STATEMENTOF CASHONHANDCASHON HAND a t t h e b e g i n n i n g o f t h e r e p o r t i n g p e r i o d ( T o t a l o f a l l f u n d s h e l d b y t h ec 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 s h o n h a nd a t t h e e n do 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 mu s 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . $

    ADD TOTAL MONEY TAKEN I N T HI S PERI ODSc h ed u l e A : Ca s h C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e d u l e A) ( * a l s o s e e i n - k i n d b e l o w) . . . . . . .Sc h ed u l e F : L o a n s Re c e i v e d t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h ed u l e H : T o t a l Sa l e s o f Camp a i g n P r o p e r t y ( A t t a c h Sc h e d u l e H) . . . . . . . . . . . . . . . . . . . . . . . .

    ( Sc he du l e H a p p l i e s t o Ca n d i d a t e s ' Co mmi t t e e s On l y )SUB- TOTAL . . . . . $ 8 , 6 7 1 . 7 5

    2 , 8 2 1 . 7 5

    5 , 8 5 0 . 0 000

    CASHON HAND a t t h e e n d o f t h i s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t b a l a n c e mus t 8 , 6 7 1 . 7 5b e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $* * UNPAI D BI L L S ( F r o m Sc he du l e D- At t a c h Sc h ed u l e D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $* I N KI ND CONTRI BUTI ONS ( F r o m Sc h e d u l e E - At t a ch Sc h e d u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $* * OUTSTANDI NG LOANS ( F r o m Sc he du l e F - A t t a c h Sc h ed u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $CANDI DATE COMMI TTEES ONLY :CONSULTANT BREAKDOWN ( Sc h ed u l e GAt t a c h ed ? )VALUE OF CAMPAI GN PROPERTY ( F r o m Sc he du l e H - A t t a c h Sc h e d u l e H)

    FORMDR- 2 DI SCLOSURE( Re v . 0 7 / 2 0 0 4 ) REPORTF o r Of f i c e Us e On l yComm . #L o g g e d I nSc a n n e dCompu t e rA u d i t e d

    L a t e r e p o r t s a r e s ub j e c t t opo s s i b l e c i v i l a n d c r i mi n a lpen al t i e s .

    DATt SHI NED

    L o c a l C o mm i t t e e s , e n t e r D a t e o f E l e c t i o n

    Co u n t y & L o c a l C o mm i t t e e s , e n t e r C o u n t y i nw h i c h E l e c t i o n i s h e l d

    000

    $ N/ AYES NO

    SUBTRACT TOTAL MONEY SPENT T HI S PERI ODSc h e d u l e B : Ex p en d i t u r e s t o t a l ( A t t a c h Sc h e d u l e B ) ( * * a l s o s e e d e b t s a n d l o a n s b e l o w) . . . . 0Sc h e d u l e F : L o a n Re p a y me n t s t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

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    Fo r I n s t r u c t i o n s , Se e Ba c k o f F or mCONTRI 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 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 )Ceda r Ra p i d s Ph y s i c i a n - Ho s p i t a l Or g a ni z a t i o n P o l i t i c a l Ac t i o n Co mmi t t e e

    STATECANDI DATES NOTE I F A CONTR I BUT I ON I S RECE I VED FROM A STATE PA C ( P OL I T I C A L AC TI ON COMMI TTEE) , L I S T THE PAC I DENT I F I C AT I ONNUMBER AND THE PAC CHECKNUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPA I GNDI SCLOSURE BOARDC A UT I O N : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Co 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 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 .

    SUB- TOTALTOTAL ( i f l a s t p a g e o f t h i s s c h ed u l e )

    $ 1 , 9 0 0 . 0 0

    * D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e m a k i n g a c o n t r i b u t i o n t o t h ec o mm i t t e e . R e l a t i o n s h i p m u s t b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n gu i n i t y ( b l o o d r 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 s b y 1 3m a r r i a g e ) . I f s u mame o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n o Page o ff a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a 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 p c o l u mn . ( f o r S c h e d u l eA)

    SCHEDULEA MONETARY( R e v . 0 7 / 0 3 ) RECEI PTSCHECK THI S BOX I FAMEND I NG FORM

    DATE PA C I D NUMBER NAME AND ADDRESS OF CONTR I BUTOR RELAT I ONSHI P AMOUNT J I F FORRECE I VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECE I VED FUND-( MM/ DD/ YR ) AND PA C CHECK ( i f a p p l i c a b l e ) RA I SERNUMBER I NCOMEI D# Ri c h ar d L . A e r t s , MD $0 1 / 1 5 / 0 5 CK# 4 0 9 Ho b b i t Dr i v e SE 1 0 0 . 0 0Ceda r Ra p i d s , I A 5 2 4 0 3I D# Da v i d K . Cr u ml e y

    0 2 / 1 5 / 0 5 CK# 7 1 1 8 Wa l d e n Rd NE 1 0 0 . 0 0Ceda r Ra p i d s , I A 5 2 4 0 2I D# Mi c h a e l E . A l ma s i0 2 / 1 5 / 0 5 CK# 5 2 5 Ev e r g r e en L n 1 0 0 . 0 0Ro b i n s , I A 5 2 3 2 8

    Mi c h a e l Hi r l e ma n , MD0 2 / 1 5 / 0 5 CK# 2 2 9 Ab bo t s f o r d R o a d SE 2 5 0 . 0 0Ceda r Ra i d s , I A 5 24 03I D# F . Mi c h a e l Eme r y , MD0 4 / 1 5 / 0 5 CK# 1 1 Sy l v a n L N SE 2 5 0 . 0 0Ceda r Ra p i d s , I A 5 2 4 0 3I D# C h r i s t i n e B o t k i n , MD

    0 4 / 1 5 / 0 5 CK# 4 7 2 3 L ep r e c h a u n L n NE 2 5 0 . 0 0Ceda r Ra p i d s , I A 5 2 4 1 1I D# Do n al d J o h n s o n , MD0 4 / 1 5 / 0 5 CK# 1 1 4 0 0 H a l i t e Bl v d 2 5 0 . 0 0Ceda r Ra p i d s , I A 5 2 5 5 2I D# He n r y Ca r s o n , MD0 4 / 1 5 / 0 5 CK# 3 8 1 0 Ceda r B l u f f Ct NE 2 5 0 . 0 0C e d a r Ra p i d s , I A 5 2 4 1 1

    L au r a Heman n , MD0 4 / 1 5 / 0 5 CK# 6 3 1 9 Us h e r s Ri d g e Rd 1 0 0 . 0 0Ceda r Ra i d s I A 5 2 4 1 1

    I D# J o h a n n a A be r n a t h y , MD0 4 / 1 5 / 0 5 CK# 2 0 7 0 Co t t a g e Gl e n Rd SE 2 5 0 . 0 0Ceda r Ra p i d s , I A 5 2 4 0 3

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    Fo r I n s t r u c t i o n s , Se e Back o f Fo r mCONTRI 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 TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f O r g a n i z a t i o n )Ce d a r Ra p i d s Ph y s i c i a n - Ho s p i t a l O r g a n i z a t i o n P o l i t i c a l Ac t i o n Co mmi t t e e

    STATE CA NDI DA T ES NOT E : I F A CONTRI BUT I ON I S RECE I V ED FROM A STATE PA C ( P OL I T I C A L AC T I ON C OMMI T T E E ) , L I S T THE PA C I D EN T I F I C A T I ONNUMBER A ND T HE P AC CHECK NUMBER I N THE DES I GNATED COLUMN A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA E T H I C S AND CAMPA I GNDI SCLOSURE BOARDC A UT I ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , 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 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

    TOTAL ( i f l a s t p a g e o f t h i s s c h e d u l e )SUB- TOTAL $ 2 , 3 5 0 , 0 0

    * D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e m a k i n g a c o n t r i b u t i o n t o t h ec o mm i t t e e . R e l a t i o n s h i p mu s t b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r 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 s b y 2 3m a