ZACK a ii' FORM " Vl13i7 W)~Il_IYILIYI

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CHECK ONE .
Tnis is an initial' Statement of Organization
Qt T jIiS is an amended` Statement of Organization
0112003)
For Office Use Only
*A- ;l:++et c.e .e . .,A.. . ~: fitred v.»tiin ±p dpys of Me c-mmittee's arcenting contributions,
CVIllrll . K
making expenditures or incurring indebtedness exceeding $750. Amendmen(W 6flpWd ke filed within 30 days of a Indexed _
change. Penalties maybe imosed
p for late-filed Statements of Organization. " ;- Audited _
Computer

COMMITTEE NAME

JA r 's ~ Sa

IMPORTANT : indicate type of committee you are reporting for : ^" w,~,
( 1 )StatewIde/Leglslative Candidate ( 2 )Statewide PAC ( 3 )State Party ( 4 )Coon 11t 1( 5 )County PAC ( 6 )Ballot Issue/Franchise
Committee ( 7 )CounttlCity Central Committee ( 8 )Support slate of candidates (iist cand)dates' ir purpose of committee)
COMMITTEE TREASURER COMMITTEE CHAIR
Name Name
1 Lt iido_ _
`Jo
Moiling Addre ,
i ' l `
i NtallinR3 Addra S
-~ Sca

6City,7aState
~q5 I rpt~~O~f 5oim.2
Zip Code
. D - & -~ ~l--O Q
City, State Zip Code
'
(2n -t ~- SDD 2 2., la--Navy 4-i c. -T--A- `jO0-- Z.-

Phone (It 2.) 2 3 ' 3 c! `J' Phone (717-) al 3 -- 3 d mar' l

e-mail e-Mail
INDICATE PURPOSE OF COMMITTEE - Check One Bax Advocate for/against candidate(s) Advocate fodagainst ballot issue(s)
Comment or description ;
T11 Candidates En r: /~1~
Office Sought : Cl SS or`a/n DiStrIW.

Political Party (if applicable) rGt6 uYtP)C Year Standing for Election . C) (D
CountylLocal Candidates and Local Ballot/Franchise Committees Enter:
County: Dare of Elec'.iion : Z Zooq
Candidate name & Address or Parent Entity (PACs, it applicable l,
Sank Account Name 4 k
Affiiiats
' e . or Sponsor
. .) D qce..
~ 4t- Sum-~Rz~ I so r ~ guss~ 11 D
Named Financial Account
Institutionltype of -1 1 Mailing Address w 1

i h t, ~ 1 ~1 0e-LVt Uniov1 (0'1 ,~39 TroLC 66so~e... Cy~e.

Mailing Address City ! State Y S-
Zip
-0 ,. v
- ~~
rSoX 06 U
30S !I(c!1/1-hiL
--
State . Zip Phone ( r I~ Z. ~' ~ ~' ~ 3
7
i -1Qv1` ~ 2h- MoD Z Z
DISPOSMON OF BALANCE OF FUNDS UPONt DISSOLUTION (Staierrient of intent-required by taw for all committees, except state parties and central
Indicate disposition of funds by marivnp appropriate number in box committees and committees using only personal funds .)
(? i DONATED TO -- COUNTY CENTRAL COMMITTEE (6) PRORATED REFUND TO CONTRIBUTORS I
i21 DONATED TO -_ LOCALIST.ATEINAT'L POLITICAL PART' rl-r!yn- ral 171 TRANSFER TO ANOTHER COMMITTEE OF THIS SAME CANDIDATE I
1
"` DONATED TO CHAR :TASLE ORGANIZATION (CANDIDATES ONLY)
(specity) (8) RETURN TO PARENT ENTITY GENERAL FUND kPACS ONLY )
(?) CITYICOUNTYISCHOOUSTATE OF IOWA GENERAL FUND (underline one) (9) OTHER (PACs ONLY), PLEASE BE SPECIFIC
j (51 PARTISAN CONGRESSIONAL DISTRICT FUND

STATEMENT OF AFFIRMATION BY TREASURER AND CANDIDATE : OR POLITICAL COMMITTEES, BY CHAIRPERSON

'. s .  e,"..Vro that 1 am required to Me disdosure reports if the oommittee receives contributions . makes expenditures . or incurs indebtedness in excess of
$750 .00 in a calendar year to expressly advocate for any candidate or ballot issue . I understand that although the treasurer normally prepares and files
reports, the candidate or chairperson (PACs) is responsible under the law for accurate and timely disclosure reports and that late-filed reports are subject
to civil penalties and possible other legal action . I understand that by filing this form, I am subject to the laws found in Iowa Code chapter 56, chapter 688
and administrate rules found in chapte~A51 . I affirm that all committee officers have been informed of their appointment and obligations .

Signature of Treasurer/I (/ Date Signed

- U . ._ / '7
f D
S cnsiure of nd"sdste . Oft, it PAC, Central Carn ttee or Local Ballot Issue, Chairperson Date Signed