Committee Disclosure Report Form
Uploaded by
Zach EdwardsCommittee Disclosure Report Form
Uploaded by
Zach EdwardsFOR INSTRUCTIONS, SEE BACK OF FORM FORM I U
DISCLOSURE SUMMARY PAGE DR-2 I DISCLOSURE
(Rev. 07/2004) REPORT
COMMITTEE NAME (Must be same as on Statement of Organization)
For Office Use Only
0 Comm . # 17 7,? 9
IMPORTANT: Indicate by # type of committee you are reporting for: L_7_~J Logged In
( 1 )Statewide/Legislative/Judge Standing for Retention Candidate ( 2 )State PAC ( 3 )State Party Scanned
(4 )County Central Committee ( 5 )County Cendidate.(6 )Cl Candidate ( 7 )School Board or Other
Political Subdivision Candidate ( 8 )County PAC-,(+! " a jJ%"rd or Other Political Computer
Subdivision PAC ( 11 ) Local Ballot Issue Audited
CANDIDATE COMMITTEES ONLY:
Candidate Name " ~
4 V 1 6 20O,1Por Party (if applicable)
Late reports are subject to
G
v possible civil and criminal
Office Sought (if Senate or House) penalties.
Co u t\A
SIGNATURE OF PERSON FILING REPORT TELEPHONE DATE SIGNED
I AM FILING A R'R REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR.
(report date) Indicate by #
Local Committees, enter Date of Election
CHECK IF AMENDMENT TO REPORT DATED
\\ a
Count & Local Committees, enter County in
Check if this is final (termination) report and attach Notice of Dissolution Form DR-3 .
(You must continue to file reports until a DR-3 is filed.) which Election is held
STATEMENT OF CASH ON HAND
CASH ON HAND at the beginning of the reporting period . (Total of all funds held by the
committee. This amount MUST be the same as the cash on hand at the end
of the last reporting period or must be zero if this is first report filed.) .......... ........ ........ ........ $
ADD TOTAL MONEY TAKEN IN THIS PERIOD
Schedule A: Cash Contributions total (Attach Schedule A) (*also see in-kind below) .. ... .....
Schedule F: Loans Received total (Attach Schedule F) . ... ..... ........ ... ...... ..... ................ ........
Schedule H: Total Sales of Campaign Property (Attach Schedule H) ..... ..... ... ..... ........ ... .....
(Schedule H applies to Candidates' Committees Only)
I
SUB-TOTAL .....$
at t"2
SUBTRACT TOTAL MONEY SPENT THIS PERIOD
Schedule B: Expenditures total (Attach Schedule B) (**also see debts and loans below) ....
Schedule F: Loan Repayments total (Attach Schedule F) ...... ........ ... ..... ........... ... ..... ... ..... ...
CASH ON HAND at the end of this reporting period (if final report balance must
be zero) (Attach DR-3) . ........ ..... ........ ............. .............. ............. ........ ........ ........ ...... ..... ... ...... $
**UNPAID BILLS (From Schedule D - Attach Schedule D) .. ...... ........ ..... ... ........ .............. ..... ... ..... ... ...$ 43
*IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedule E) . ..... ........ ... ..... ...... ...................$
"'"'OUTSTANDING LOANS (From Schedule F - Attach Schedule F) .. ... ..... ... ..... ... ..... ...... ........ ........ ...$
CANDIDATE COMMITTEES ONLY:
CONSULTANT BREAKDOWN (Schedule G Attached?) YES
VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H) $
FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
E IN KIND
COMMITTEE NAME (Must be same as on Statement of Organization) (Rev . 06/97)1 CONTRIBUTIONS
G -Rl) ~l~ll V4n0
. 5 1 `Z~ J , i 5 Q,
CHECK THIS BOX IF
AMENDING FORM
DATE RELATIONSHIP DESCRIPTION ESTIMATED v IF FOR
RECEIVED NAME AND ADDRESS TO CANDIDATE OF IN KIND FAIR MARKET FUND-RAISER
(MM/DD/YR) OF CONTRIBUTOR ' (if applicable) CONTRIBUTION VALUE CONTRIBUTION
$
'W6ZOr\ a ."n
~;T o
c~. ZR
\o~'a(o ~ ~ Cw~lc,~
Rs F oo l
'Disclosure law requires candidates to disclose the relationship of any relative making an in kind contribution to the Page of
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives (for Schedule E)
by marriage) . (See Page 2 of forms packet.) If surname of contributor is the same as candidate, but there is no
familial relationship, enter "not applicable" in the relationship column .
Notice of Dissolution FORM
DR-3
1 (Rev. 07103)
Reset FoTni NOTICE OF
DISSOLUTION
Mail to :
IECDB
510 East 12`h , Suite 1 A ry. For Office Use Only
Des Moines, Iowa 50319 4& iiar,3
Indexed
Nov 16 2004 Audited
Computer
Certified Date of Dissolution
COMMITTEE NAME
Fad S C Q,
Official Name of Committee
O
Street
5
City, State, Zip Code
3CW3
Area Telephone
Code
WHEN TO FILE:
The Notice of Dissolution must be filed within thirty (30) days of completion of all the following:
1. All debts, loans and obligations have been paid or transferred;
2. All campaign funds have been spent;
3. All campaign property sold or transferred (candidates only); and
4. A final report disclosing all transactions closing the committee .
For state candidates and state PACs, a final bank statement must be filed with the Notice of Dissolution or as soon as
possible ifthe bank statement is not available at the time the Notice of Dissolution is filed .
S ignature of Candidate or Treasurer (if candidate's committee)/Signature of Chair or Treasurer (if PAC)
Date Signed
FOR INSTRUCTIONS, SEE BACK OF FORM
This form is not applicable to statutory political committees.
