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FOR I NSTRUCTI ONS, SEE BACK OF FORM

DI SCLOSURE SUMMARY PAGE

COMMI TTEENAME( M u s tb es amea so n S t a t e m e n to fO r g a n i z a t i o n )

f i a t - p e rf o rs t s t er e p

I MPORTANT : I n d i c a t eb y # t y p eo fc o m m i t t e ey o ua r er e p o r t i n gf o r: I I I( 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 eS t a n d i n gf o rR e t e n t i o nC a n d i d a t e(2 ) S t a t ePAC( 3 ) S t a t eP a r t y( 4 ) C o u n t yC e n t r a lCo mmi t t e e ( 5) 6 ) C~ C p nA 1t o (7 ) S c h o o lB o a r do r O t h e rP o l i t i c a lS u b d i v i s i o nC a n d i d a t e( 8 ) 3"" , ' c o IBo a r d o rO t h e rP o l i t i c a lS u b d i v i s i o nPA C( 1 1 )L o c a lB a l l o t

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STATEMENT OF CASH ON HAND

CASHON HANDa tt h eb eg i n n i n go ft h er e p o r t i n g p e r i o d. ( T o t a l o fa l lf u n d sh e l db yt h ec o mmi t t e e. Th i sa m o u n tMUSTb e t h es amea s t h ec a s h o nh a n da t t h ee n do ft h el a s tr e p o r t i n g p e r i o do r mu s t b ez e r o I ft h i si sf i r s tr e p o r tf i l e d. ) . . . .. . .. . . . . . . . . . . . .. . . . . . . . . . . . . .$ADDTOTALMONEYTAKENI NT HI SPERI OD '

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S c h ed u l eF: L o a n sRe c e i v e dt o t a l( A t t a c hS c h e d u l eF ).

. . . . . . .. . . . .? 1 6 . . . .. ~ .. ~. . . .i ..0 _0S c h ed u l eH: T o t a lS al e so fC a mp a i g nP r o p e r t y( A t t a c hS c h e d u l eH). .. . . .. .. .. . . . . . .. .. . . . . . . . . . .. .. .

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S c h ed u l eB: Ex p 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 ed e b t sa n dl o a n sb e l p w j ,. . .S c h ed u l eF: L o a nRe p a y m e n t st o t a l( A t t a c hS c h ed u l eF ). .. . . .. . . .SL 6 .. . .. .. y.. .. t. .... . . . .. . . . .. . .

CASHONHANDa t t h ee n do ft h i sr e p o r t i n g p e r i o d( i ff i n a lr e p o r tb a l a n c em u s tb ez e r o )( A t t a c hDR - 3 ).. . . . . .. . . . . . . .. . . . . . . .. .. ... . . . . . . ... . .. . . . .. . .. . . ... . .. . .. .. . . .. . . . .. . . ... . . .... .. . . . ... . .. . .. . ... .. .. ..$

* " U N PA I DB I L L S( F r o mS c h e d u l eD-A t t a c hS c h e d u l eD).. . . . . .. . . . .. . . . . .. .. . .. . . . .. . .. .. . .. . .. .. ... .. .. . . .. ... ,. . .. .. .$* I NK I NDCONTRI BUTI ONS( Fr o m S c h e d u l eE - A t t a c hS c h e d u l eE) . .. ~ ~.. ~ . . . . ... 6 . . , ~ $* * OUTSTANDI NGLOANS( Fr o m S c h e d u l eF -A t t a c hS c h e d u l eF ). . .. . .. . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . .. . . . . .. . . . . . .$CANDI DATECOMMI TTEE SONLY:

CONSULTANTBREAKDOWN( S c h e du l eG A t t a c h e d ? )VALUE OFCAMPAI GNPROPERTY( F r o mS c h e d u l eH - A t t a c hS c h e d u l eH) $

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CONTRI BUTI ONS - -MONEY TAKEN I N( I n c l u d i n gc an di d at e ' s p er s o na l f u n ds )

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

/ 7 / 9 t " e i ' / fo r " S' - e Pe e e -

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

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STATE CANDI DATES NOTE : I FA CONTRI BUTI ONI SRECEI VEDFROM A STATE PAC ( P OL I T I CALACTI ONCOMMI TTEE) ,L I S TTHE PAC I DENT I 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 SCLOSUREBOARD .

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 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 of o r an y c o mme r c i a l p u r p os eb y an y p er 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 n di d at e c o mmi t t e es t o d i s c l o s et h e r e l a t i o n s h i po f an y r e l a t i v ema k i n g a c o n t r i b u t i o nt o t h ec o mmi t t e e. R e l a t i o n s h i pmu s t b e s h own t o t h e t h i r dd e g r e e o f c o ns an g ui n i t y( b l o o dr 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) ( S ee Pag e 2 o f f o r ms p ac k e t. ). I fs u r n ame o f c o n t r i b u t o ri s t h e s ame a s c a n di d at e , b u t t h er e i s n o P a g e -~_ o f _f a mi l i a lr e l a t i o n s h i p ,e n t e r " n ot a pp l i c ab 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 e d u l eA)

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

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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 np r o p e r t yc 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 ef e rt oSc h e d u l eH i n s t r u c t i o n s. )

Ex p en d 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 d v 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 smus t a l s o b ed e t a i li t e mi z e do nSc h e d u l e G b y t h eamoun t , p u r p o s e , a n d d at e o fe a c h t y p e o f e xp en di t u r emade b y t h e p e r s o n l e n t i t yo n b e ha l fo f t h e c an di d at 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 8 8A . 4 0 2 ( 3 ) ( i ). )

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

FOR I NSTRUCTI ONS, SEE BACK OF FORM 1 ' , P t) ' a SCHEDUL E

EXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT( R ev. 0 7 / G3 ) EXPENDI TURES

STATE 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 CHECK THI S BOX I FPACCHECK NUMBER FOR EACH EXPENDI TURE. A L I STOF I DNUMBERS I SAVAI LABLEFROM THE I OWA AMENDI NG FORMF THI CS& CAMPAI GNDI SCLOSUREBOARD .

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 TO WHOM PURPOSE AMOUNTDATE I DNUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

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No t i c eo f Di s s o l u t i o n

1 . A l ld e b t s ,l o an sa n d o b l i g a t i o n sh av e b e e n p a i do r t r a n s f e r r e d;2 . A l lc a mp a i g n f u nd sh av e b ee n s p e n t ;3 . A l lc a mp a i g n p r o p e r t y s o l do r t r a n s f e r r e d( c a n d i d a t e so n l y ); a n d4 . A f i n a lr e p o r td i s c l o s i n ga l lt r a n s a c t i o n sc l o s i n gt h e c o mmi t t e e.

COMMI TTEE NAME

Da t eSi g n e d

FOR I NSTRUCTI ONS, SEE BACK OF FORMTh i s f o r m i s n o t ap pl i c ab l e t o s t a t u t o r yp o l i t i c a lc o mmi t t e e s.

FORM ( Re v . 0 7 / 0 3 )

DR- 3NOTI CE OF

DI SSOLUTI ON

Fo r Of f i c eUs e On i v

Comm . #I n d e x e d

Au d i t e dCompu t e rC e r t i f i e dDa t eo fD i s s o l u t i o n

WHEN TO FI L E:Th e N o t i c eo f D i s s o l u t i o nmus t b e f i l e dw i t h i nt h i r t y( 3 0 )day s o f c o mp l e t i o no f a l lt h ef o l l o w i n g:

Fo r s t a t ec a nd i d a t e sa n d s t a t ePACs , a f i n a lb a n k s t a t e me n tmu s t b e f i l e dw i t ht h eNo t i c eo f D i s s o l u t i o no r a s s o o n a sp o s s i b l ei f t h eb a n k s t a t e me n ti s n o t a v a i l a b l ea t t h e t i me t h eNo t i c eo f Di s s o l u t i o ni s f i l e d.

Si g na t u r eo f Ca nd i da t eo r T r e a s u r e r ( i fc a 6 d i d a t e ' sc o mmi t t e e ) / S i g n a t u r eo f Ch a i ro r T r e a s u r e r( i fPAC)

r 71 , 0 1V V1 1e I V 1 g :: 2 0 , - e l e &elO f f i c i a lName o f Co mmi t t e e

S t r e e t

C i t y ,S t a t e ,Z i pCode

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