IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

510 EAST 12th, SUITE 1A VERIFIED STATEMENT

Reset , Forln , REGISTRATION
DES MOINES, IA 50319 (Out-of-State Committees)
www.iowa.gov/ethic s (Rev. 07/03)
VERIFIED STATEMENT REGISTRATION For office use only
(Out-of-State Committee) Comm . #
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE .
Audited
QVN~..cc~l rH EACH',CONTRIBU DTION TO THE IOWAOCOMMITTEE WITH TIH
O E CONTRIB U TION . Checked
PLEASE DEFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .
THIS FORM MbST BE FILED FOR EACH CONTRIBUTION IN EXCESS OF $50 Computer ------- --------___

di*MI?TEE NAME
Official Name of Out-of-State Committee Do not abbreviate committee name . Written explanation must be provided for Acronym) .
LOCAL 150 - INTERNATIONAL UNION OF OPERATING ENGINEERS
Mailing Address
6200 Joliet Road
6C&25State, Zip Code Ar98s;od; 482-BT&hone No .
Countryside, IL

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
IS REGISTERED OR OPERATES (Use separate page if needed to list more than one entity)

- ILLINOIS BOARD8?tfV6We9 -LOCAL 150 - I_ .U_.OO_.E_. LO_A_TA_REA__P .A__._C ._I_._D ._#__8_1_7_8

Mailing Address Mailing Address
P .O . Box 4187 6200 Joliet Road
--------- - --
e1ZdPIY,°Q756
~ Telephqge, ity, State, Zip Code
----_--__------------ 7824141
__-___-_-------___- Countryside, IL 6052----_--------- -__--__---_-__-__

PURPOSE OF COMMITTEE

TO SUPPORT CANDIDATES AND ISSUES FOR WORKING MEN AND WOMEN

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Joe Farrell Lincoln for Sheriff
_______________-___-_Mailing
--------------------------------------------------
Mailing Address Mailing Address
318 5th Street 1024 Springbrook Lane, DeWitt, IA 52742
- ------ --------- --------------- --- -------
City, State, Zip Code Telephone Date If In-end Contribution, Describe
De Witt, IA 52742 708 224_1714
----- )-------___-
10/28/04
~
Amount
$ 500 .00
Check #
2666 r Committee . ID #
17124

VERIFIED STATEMENT OF COMMITTEE :

I -SIL_Y_I_0_A_. _BARRT0_L_0_ _, attest that the contribution reported above is accurate and that the information about this out-of-state
committee is correct and accurate to the best of my knowledge. I also attest that the reports filed in the named jurisdiction comply with requirements that are
substantially similar to Iowa Code section 68A.6, including the disclosure of all contributions received and all expenditures made. I further attest that the
contribution rep ed above was made tom account that does not accept contributions from corporations or other prohibited contributors under Iowa Code
section 6, 4unle the tea t c mittee is a ballot issue committee. I understand that potential civil and criminal penalties may gpply unless a copy of
this for " een f It e to a . Campaign Disclosure Board within 15 days of the date of the contribution .

STAFF ACCOUNTANT _
(Title) (Date)