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DI SCLOSURE SUMMARY PAGE

I AM F I L I NG AJ 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 e

I 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 r

P 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- 180

SI 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 CASHONHAND

CASHON 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 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 s h o n h a nd 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 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 OD

Sc 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 0

0

0

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)

FORM

DR- 2 DI SCLOSURE

( Re v . 0 7 / 2 0 0 4 ) REPORT

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

Comm . #

L o g g e d I n

Sc a n n e d

Compu t e r

A 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 o

po s s i b l e c i v i l a n d c r i mi n a l

pen 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 n

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

0

0

0

$ N/ A

YES NO

SUBTRACT TOTAL MONEY SPENT T HI S PERI OD

Sc 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) . . . . 0

Sc 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



Fo r I n s t r u c t i o n s , Se e Ba c k o f F or 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 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 ON

NUMBER 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 BOARD

C 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- 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 )

$ 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)

SCHEDULE

A MONETARY

( R e v . 0 7 / 0 3 ) RECEI PTS

CHECK THI S BOX I F

AMEND 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 SER

NUMBER I NCOME

I D#Ri c h ar d L . A e r t s , MD

$0 1 / 1 5 / 0 5CK# 4 0 9 Ho b b i t Dr i v e SE

1 0 0 . 0 0

Ceda r Ra p i d s , I A 5 2 4 0 3

I 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 0

Ceda r Ra p i d s , I A 5 2 4 0 2

I D#Mi c h a e l E . A l ma s i

0 2 / 1 5 / 0 5 CK# 5 2 5 Ev e r g r e en L n1 0 0 . 0 0

Ro 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 0

Ceda 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 0

Ceda 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 , MD0 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 0

Ceda r Ra p i d s , I A 5 2 4 1 1

I D#Do n al d J o h n s o n , MD

0 4 / 1 5 / 0 5 CK# 1 1 4 0 0 H a l i t e Bl v d2 5 0 . 0 0

Ceda r Ra p i d s , I A 5 2 5 5 2

I D#He n r y Ca r s o n , MD

0 4 / 1 5 / 0 5 CK# 3 8 1 0 Ceda r B l u f f Ct NE 2 5 0 . 0 0

C 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 0

Ceda r Ra i d s I A 5 2 4 1 1I 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 0

Ceda r Ra p i d s , I A 5 2 4 0 3



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



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 ON

NUMBER A ND T HE P AC CHECK NUMBER I N THE DES I GNATED COLUMN A L I S T OF I D NUMBERSI 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 BOARD

C 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 r

f 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 r r i a g e ) . I f s u r n a me 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 f _f 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 m n ( f o r S c h e d u l e A )

SCHEDULE

A MONETARY

( R e v . 0 7 / 0 3 ) RECEI P T S

0 CHECK T HI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAMEAND ADDRESS OF CONTR I B UTOR R EL A T I ONS HI P AMOUNT J I F FORRECE I VED ( i f a p p l i c a b l e ) T O CANDI DATE ' RECEI VED FUND-( MM/ DD/ YR ) A ND P AC CHECK ( i f a p p l i c a b l e ) R AI S ER

NUMBER I NCOME

I D#Ke v i n Mu r r a y , MD& J a n Me r f e l d , MD

$0 4 / 1 5 / 0 5CK#

1 8 3 Ab bo t s f o r d Rd5 0 0 . 0 0

Ce d a r Ra p i d s , I A 5 2 4 0 3

D#Ho l l y B r o wn , MD

0 4/ 1 5 / 0 5 CK# 9 0 0 Ha mp s h i r e Dr i v e2 5 0 . 0 0

Ma r i o n , I A 5 2 3 0 2

I D#J am e s Bu r k e & Ma r i a Do c e , MD

0 4/ 1 5 / 0 5 CK# 4 3 4 0 Co t t a ge Gr o v e P a r k w a y SE 2 0 0 . 0 0

Ce d a r Ra i d s , I A 5 2 4 0 3

I D#Mi c h a e l B r o o k s , MD& V i c t o r i a B r o o k s

0 4 / 1 5 / 0 5 CK# 1 5 8 4 F o r e s t Gr o v e Rd 2 5 0 . 0 0

Ce d a r Ra i d s , I A 5 2 4 0 3

I D#T h a n o m s a k Ku l l a v a n , MR&P a t t a y a Ku l l a v a n , MD

0 4/ 1 5 / 0 5CK# 2 6 0 3 Wa s h i n gt o n St 2 5 0 . 0 0

I o wa C i t y , I A 5 2 2 4 5

I D#Y a n g A l m, MD

0 4/ 1 5 / 0 5 CK# 9 2 5 5 A t l a n t i c Dr i v e SW

2 5 0 . 0 0

Ce d a r Ra p i d s , I A 5 2 4 0 4

I D#Ke i t h Wr i g h t , MD

0 4/ 1 5 / 0 5CK#

3 7 0 0 An t e l o pe Ct NE 2 5 0 . 0 0

Ce d a r R a p i d s , I A 5 2 4 0 2

I D#De a n Ge s me , ME

0 4/ 1 5 / 0 5 CK# 4 3 6 5 Fo x Mea do w Dr i v e SE2 0 0 . 0 0

Ce d a r R a p i d s , I A 5 2 4 0 3

I D#L e i l a K u t t e h , MD

0 4/ 1 5 / 0 5 CK# 9 2 55 De e r Vi e w Rd1 0 0 . 0 0

Ce d a r Ra i d s , I A 5 2 4 1 1

I D#A b b y T h r o we r , MD

0 4/ 1 5 / 0 5 CK# 8 B r o wn Dee r C i r c l e 1 0 0 . 0 0C o r a l v i l l e , I A 5 2 2 4 1



F o r I n s t r u c t i o n s , Se e Ba c k o f F o r m



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 )

Cedar Ra p i d s Ph y s i c i a n- H o s pi t a l Or g an i z a t i o n P o l i t i c a l Ac t i o n Commi t t e e

STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED F ROM A STATE PAC ( POL I T I CAL ACTI ON COMMI TTEE) , L I ST THEPAC I DENTI F I CATI ON

NUMBER ANDT HE PACCHECKNUMBER I N THE DESI GNATED COLUMN.A L I S T OF I D NUMBERS I S AVA I LABLE F ROM THE I OWA ETHI CS AND CAMPAI GNDI SCL OSURE BOARD .

CAUTI ON : Se ct i o n 68B . 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 pi e d f r o m r e p o r t s a nd s t a t e me 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 r

f o r any c omme r c i a l p u r p o s e b y a n y p er s o n o t h er t h an s t a t u t o r y p o l i t i c a l c o mmi t t e es .

SUB- TOTAL

TOTAL ( i f l a s t p a g e o f t h i s s c h e du l e )

D i s c l o s u r e l a w r e q u i r e s c a nd i d a t e c ommi 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 an y r e l a t i v e mak i n g a c o n t r i b u t i o n t o t h ec o mmi t t e e R e l a t i o n s h i p mus 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 ) an d a f f i n i t y ( r e l a t i v e s b y 3 3ma r r i a g e ) . I f s u r n a me 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 ut t h e r e i s n o Page of_

f a mi 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 Sc h e du l e A)

SCHEDUL E

A MONETARY

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

Q CHECK T HI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSH I 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/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOME

I D #Ci n d y Ro e hr

$0 4 / 1 5 / 0 5CK# 3 2 0 McKi n s i e Ct NE 2 5 0 . 0 0

Ceda r Ra p i d s , I A 5 2 4 0 2

1 D #To r k Har man, MD

0 4 / 1 5 / 0 5CK# 4 8 2 5

Dee r Vi e w Rd1 0 0 . 0 0

Cedar Ra p i d s , I A 5 2 4 1 1

I D#Ma r t i n Wi e s e n f e l d , MD

OS / 1 5 / OS CK# 4 3 2 5 P i o n e er Tr a i l SE1 0 0 . 0 0 E l

Cedar Ra i d s , I A 5 2 4 0 3

I D#J ef f r e y Cl a r k , MD

0 5 / 1 5 / 0 5 CK# 5 2 0 Ve r n o n Dr SE 2 5 0 . 0 0 E ]Cedar Ra i d s , I A 5 2 4 0 3

I D#L a r r y Do n a l d s o n

0 5 / 1 5 / 0 5 CK# 3 2 0 0 L i n de n Dr i v e SE 2 5 0 . 0 0


I D #Ga i l Va n d e wa l k e r , MD&Ke v i n Kopesky

0 5 / 1 5 / 0 5 CK# 1 4 0 Du n d r e n n a n L a n e 2 5 0 . 0 0Ma r i o n , I A 5 2 3 0 2

I D#J e an et t e We r l i n g

0 5 / 1 5 / 0 5 CK# 2 5 3 3 Bl u e Ri d g e Dr i v e NE 4 0 0 . 0 0


I D#CK#

l D#CK#

I D#CK#

Download - Cedar Rapids Physician-Hospital Organization PAC__9694__scanned

Download - Cedar Rapids Physician-Hospital Organization PAC9694scanned