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8/7/2019 Boettger Nancy__890__scanned
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FOR I NSTRUCTI ONS, SEE BACK OF FORM
DI SCLOSURE SUMMARY PAGE
CO MI 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 )
n c.
o e ~
I -
S 7e 4 1 Q 7
r
I MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y ou a r e r e p or t i n g f o r :
( t ) S t a t e w i d e / L e g i s l a t i v e Ca n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C ou n t y / L o c a l Ca n d i d a t e( 5 ) C o u nt y PAC ( 6 ) B a l l o t I s s u e / F r a nc h i s e Co mmi t t e e ( 7 ) C o u n t y / C i t y C e n t r a l Co mmi t t e e( 8 ) S u pp o r t S l a t e o f Ca n d i d a t e s
7/, 2 - 7 y y , 3, a 7 0 t
_
I GNATUR
F TREASURER
p e r s o n f i l i n g t h i s r e p o r t )
EPHONE
DATE SI GNED
Pe n a l t i e s Due For L a t e F i l e d Repo r t s Range f r o m $10 t o X 4 0 , 0 ,
SEE I NSTRUCTI ONS ON BACK AND COMPLETE THE FOLLOWI NGSENTENCE :
I AM F I L I N G A
~a~~
f )
6 C - .
REPORT FORAN/ A ( 1 ) ELECT I ON /
( r e p o " t e )
( ] CHECK I F AMENDMENT TO REPORT DATED
0C h e 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 o r m DR- 3 .( Y o 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 N o t i c e o f D i s s o l u t i o n i s f i l e d . )
ST ATEMENT OF CASH ON HAND
I n d i c a t e o
CASH ON 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 h i s i s t h e t o t a l
o f a l l mo n i e 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 es a m e a s t h e c a s h o n h a n d 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
X07-
ADD TOTAL MONEY TAKEN I N T HI S PER I OD
Sc h e d u l e A : C a 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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FORM
DR- 2DI SCLOSURE( Re v . 1 1 / 9 7 )
REPORT
F o r O f f i c e Us e O n i v
Comm . t t
I n d e x
A u d i t e d 1 9 - 1 -1 - 0 1
C o m p u t e r
C l -
AN 1 6 2 0 0 2
N- E LECT I ON YEAR .
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
C o 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 nw h i c h E l e c t i o n i s h e l d
x ' 7 _ 7 5 - 60
Cr - '
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Fo r I n s t r u c t i o ns , Se e Ba c k o f F o r t h
. CONTRI BUTI ONS - MONEYTAKENI 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 )
SCHEDULE
A MONETARY
( Re v . 0 6 1 9 7 ) I
RECEI PTS
QCHECK T HI S BOX I F
AMENDI NG FORMCOMMI TTEE NAME ( Mu s t b e s ame a s o n St a t eme n t o f Or g a n i z a t i o n)
c t , t l t -
go c ~f i L
r Co r Sr tt a ~ E ' c
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~ - o
STATE CANDI
TES NOTE : I F ACONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I D E NT I F I C A T I O N
NUMBER AND THE PAC CHECK NUMBER 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 CAMPAI GNDI SCLOSURE BOARD .
CAUTI ON: S e c t i o n 6 8B . 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 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 me nt 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 ny c ommer c i a l p ur 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 es .
DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT J I F FOR
RECE I 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# - -
~l ~` l o f CK#$
/ Y ! ` l ~ - s i So 3 - 53 G ~ _ 775. o c ~
I D# 6 0 6, 3 Cc~ a. . . . ~z5c~~~~/ ~ CK#
s o S : S r - e . . . . s ~. . 3 - 33 _ 4 ~ 0 . 00
l ` l 4 1. SO_ - 30 7 - - 0 2 . 3 - 7 r
1 D# ( f o o07T. - - ( e
7j rt - o c t Its
y / - 26 / 0 ~ CK# ~ ~ 1 1 - 3 ` l ~` Yo o o' ~~ Y$sue - 7c l ~
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F o r I n s t r u c t i o n s , Se e B a c k o f Fo r 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 S t a t e me n t o f Or g a ni z a t i o n)
SCHEDULE
A MONETARY
( Re v . 0 6 / 9 7 ) IRECEI PTS
Q CHECK THI S BOX I FAMENDI NG FORM
) ( , 14. K C. U d ~ ee ' _ Z` qe r~ ' a t , ^ S- 1 ' a
eS
n e L " ~e LbYnmrV
STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) . L I S T THE PAC I D EN TI F I CA T I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .
CAUTI ON : Se c t i o n 6 8 8 . 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 m a t i o n c op i e d f r o m r e p o r t s and s t a t e me nt 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 ny c o mme r c i a l p u r p o s e b y a ny 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 ommi t t e e s .
DATE
PAC I D NUMBER
RECEI VED
( i f a p p l i c a b l e )
( MM/ DD/ YR)
AND PAC CHECK
NUMBER
I D#
6 6 ` 7 _ 3
CK#3 9
I D # ~. 3 aY
I ' Y I e _ r ' c J
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C
I D#
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CK#
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NAME ANDADDRESS OF CONTRI BUTOR
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RELAT I ONSHI P
AMOUNT
J I F FOP
TO CANDI DATE'
RECEI VED
FUND-
( i f a p p l i c a b l e )
RAI SERI NCOME
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Fo r I n s t r u c t i o n s , See Back o f Fo r m
CONTRI BUTI ONS - MONEYTAKENI 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 e me n t o f Or g a n i z a d on )
STATE CANDI DATES NOTE : I F A CONTRI BUT I ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I DE NT I F I C AT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .
CAUTI ON : Se 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 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 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 rf o r a ny c omme r c i a l p u r p o s e b y a ny p er 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 es .
SCHEDULE
A MONETARY
( Re v . 0 6 1 9 7 ) RECE I PTS
CHECK T HI S BOX I F
AMENDI NG FORM
DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR REL A TI ONSH I P AMOUNT J I F FOR
RECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE' RECE I VED FUND-
( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI S ER
NUMBER I NCOME
1 D# t o 6o 2 7
_ aqxd_~ILX[L- _
. S0 , 3 oR ; ~ SC7
1 1 9 / 0 / CK# i °. Zdl ~ / v s / o v , o ,
5 1 / yI D# 4e67v
C, ' ~ ~ ~l SO" a v
> ' a Z v 0 ( CK# - 2 - 5 5SO307 P73
I D# WW,R - 2 1 0 6
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FOR I NSTF?UCTI ONS, SEE BACKOFFORM SCHEDULE
EXPENDI TURES - - MONEY SPENT FROM COMMI TTEE ACCOUNT B MONETARY
( Re v . 0 9 / 9 7 ) EXPENDI TURES
STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLAT I VECANDI DATES . L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN ANDTHE CHECK T HI S BOX I F
PAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD.
C0?AM 7TEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i o n ) .
CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCR I BE TRANSACTI ON) EXPENDED
EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE( MM/ DD/ YR ) AND PAC
CHECK
NUMBER
D#
CK# 5- 7 , 1 t 4 , $ 3q,00
113Cl
v l CK# 5
/ Y ) o ~~ l ~5 r Ss"S
I D #q
S(Ss
I D #
/ / 3 0 / 0( CK# 6 - 7 1 7
l 2 ~ d
S .wi S.-oc~ T~, i G59 7 p ,
Si 5U
l ~3 0 l d / CK# S~ . ~C~ . " 6 Q 8 2 . . 5
8 c ,
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FOR. I NSTRUCTI ONS, SEEBACKOFFORM SCHEDULE
EXPENDI TURESB MONETARY
- MONEY SPENT FROM COMMI TTEE ACCOUNT( R e v . 0 9 / 9 7 ) EXPENDI TURES
STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLAT I VE
CANDI DATES, L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE 0 CHECK T HI S BOX I F
PAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD.
COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i o n )
AR ?) or -- I ( 1 - T c v , i 4 c r 4A cS a
CANDI D E NAME AND ADDRESS TOWHOM PURPOSE AMOUNT
DATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED
EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE
( MM/ DD/ YR) AND PACCHECK
NUMBER
I D# C O t ~ : J
J I `~!U CK# A~ o l -C _L+0 S3 - 7
P 7 ., - o X5 , 3~ r r ~ / D/ CK# ~
b. J M6
-
3 r - 1, o
I D # Co _ ,
c c -3~/ / 6 /
6/ CK#6c > r n
- Sr S 3I D # r 4 ~ ,
6 31 ~
D# S c o & - - h z
l f a l 6 / CK#Cc . ~ , , $ a m0 7
/ o _ . f i 3 , f xa
I D # 5 AA- - - Co
. 2 7
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FOR I NSTRUCTI ONS, SEEBACK OF FORM
EXPENDI TURES - - MONEY SPENT FROM COMMI TT EE ACCOUNT
STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR L EGI SL AT I V ECANDI DATES, L I S T THE CANDI DATE I D ENT I F I CAT I ON NUMBER I N THE DES I GNATED COLUMN AND THE
PAC CHECK NUMBER FOR EACH EXPEND I TURE . A L I S T OF I D NUMBERS I S AVAI L ABL E FROM THE I OWAETHI CS & CAMPAI GN DI SCLOSURE BOARD .
SCHEDULE
B MONET ARY
( Re v . 0 9 / 9 7 ) IEXPENDI TURES
CHECK T HI S BOX I F
AMENDI NGFORM
COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a ni z a t i on)
~ ~ ' t - - M, ' - r
. t ~ o r
a - d e - S-na
le t _°o r n mi
e _ e ,
DATE
EXPENDED
( MM/ DD/ YR)
9 1 1 6 1 0 (
CANDI DAE
I D NUMBER( i f a p p l i c a b l e )
AND PACCHECK
NUMBER
CK# ,i o 0
CK# o S
NAME AND ADDRESS TOWHOMEXPEND I TURE
( D i s b u r s e me n t ) WAS MADE
DesM1- f r 1 - e 5 . i - 6 , Sa3f . 2
U/. 4~ , c r , - ~ t a ~c . t R- P . a ~. ~
P . 0 n , 6y y ~®~y3
Sf 1 o" , ) I d - G3 i 7 y
PURPOSE
( D ESCRI B E TRANSACTI ON)AMOUNT
EXPENDED
L y~ t r - ~~a - ~ " o
s - n a
c a m f l ~
b . oo
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FOR I NSTRUCTI ONS, SEE BACK OF FORM SCHEDULE
EXPENDI TURES B- MONEYSPENTFROMCOMMI TTEEACCOUNTMONETARY
( Re v . 0 9 / 9 7 ) EXPENDI TURES
STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE ORLEGI SLATI VECANDI DATES, L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE CHECK THI S BOX I F
PAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA AMENDI NG FORMETHI CS b CAMPAI GN DI SCLOSURE BOARD .
COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g an i z a t i o n )
f i er I f or Sf aj cSeh t l ~ c m1' y ) 1 f T c P_
CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCR I BE TRANSACTI ON) EXPENDED
EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE( MM/ DDNR) AND PAC
CHECK
NUMBER
I D# _
013 t l o t CK# $ ; 25 , a 0
I D#
CK#
~ ~ l - -I D# , b x - , a ( a - _
10131161 CK#P v Q 130 P" / ' . . ~~` 6 - - c )
~/ 01. ~ / i CJ f ~ CX0~ SoaUZ ` l
IN 1 - .
S r ~ 3 f
I D#
a2- 0 C )
I D# ~ t i C r o - c c ~ e . = ~
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, FOR I NSTRUCT I ONS, SEE BACK OF FORM SCHEDULE
EXPENDI TURES B MONETARY- - MONEY SPENT FROM COMMI TTEE ACCOUNT
( Re v . 0 9 / 9 7 ) EXPENDI TURES
STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLATI VECANDI DATES, L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE CHECK THI S BOX I F
PAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD .
COMMI TTEE NAME ( Mu s t b e s a m e 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 )
4 r ! L t - al ~dr c - C , u ~ . e
(CANDDAW NAME AND ADDRESS TOWHOM PURPOSE AMOUNT
DATE I D NUMBER EXPEND I TURE ( DESCRI BE TRANSACTI ON) EXPENDED
EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE
( MM/ DD/ YR) AND PAC
CHECK
NUMBER
16AV o /( 3 4 0 - - S ow I ( p
I D#
t o ; / d r CK#P0
m- . S C )o
I D#
s f ~ ~ ~ , w , r h ~ 6 3 r 7 9
P o , Q 13 o ~S o 0Y
I N
1~~6j oc K# - , 7 ' ~ ~c ! o
-
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. F OR I NSTRUCTI ONS, SEE BACK OF FORM SCHEDULE
EXPENDI TURESB MONETARY
- - MONEY SPENT FROM COMMI TTEE ACCOUNT( Re v . 0 9 / 9 7 ) EXPENDI TURES
STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR LEGI SLAT I VEOCHECK T HI S BOX I F
CANDI DATES, L I S T THE CANDI DATE I DENT I F I CAT I ON NUMBER I N THE DESI GNATED COLUMN AND THE
PAC CHECK NUMBER FOR EACH EXPENDI TURE.A L I S T OF I D
NUMBERS I S AVAI LABLE FROMTHE I OWA AMENDI NGFORM
ETHI CS & CAMPAI GN DI SCLOSURE BOARD .
COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g a n i z a t i o n)
Na t v et t r f ` o r _ 5 9 ' a 1 C. - -Se QL e a I YL i L
CANDI D NAME AND ADDRESS TOWHOM PURPOSE AMOUNT
DATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED
EXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE
( MM/ DD/ YR) AND PACCHECK
NUMBERI D#
NO - s oC" CA 1 - t ( o S I
CK#
I D # _ , i
CK#
1 D #6 1 )
I _/ 1 - , ~ / , j - ~ ) W6 - ( 6 - 3 1
l
7 7
I D# Y41 7 LCd l ~
i 2 3 / I c K# s s
I D #
° ~ CK#
D#
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FOR I NSTRUCTI ONS, SEE BACK OF FOR' -
COI I I I MI T TE E NAME ( Mu s t b e s ame as o n S t a t e me n t o f O r g a n i z a t i o n )
,
I -
NOTE : De b t s p r e v i o u s l y r e p o r t e d t h a t r e ma i n u n p a i d mu s t b e i n c l u d e d o n t h i s
S c h e d u l e , a s w e l l a s an y n ew o b l i g a t i o n s i n c u r r e d i n t h i s p e r i o d .
SCHEDULE
D I NCURRED
( Re v 0 2 / 9 8 ) 1 I NDEBTEDNESS
0 CHECK T HI S BOXI F AMENDI NG
FORM
An ' i n c u r r e d d e b t ' i s a d eb t f o rDEBTSI OBL I GAT I ONS RE MA I NI NG THI S REPORT I NG PER I OD
g o o d s o r s e r v i c e s o r d e r e d o r
( DO NOT I NCLUDE LOANS - SHOWLOANS ON SCHEDULE F )
r e c e i v e d , b u t n o t p a i d f o r b y t h e
en d o f t h e r e p o r t i n g p e r i o d . ,
r e g a r d l e s s o f wh e t h e r an i n v o i c e
h a s b een r e c e i v e d .
DATE
I NCURRED
( MM/ DDNR)
NAME AND ADDRESS OF PERSON
TOWHOM DEBT OR OBL I GAT I ON I S OWED
BALANCE OWED AT
CLOSE OF
REPORTI NG
PERI OD'
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FORI NSTRUCTI ONS, SEE BACK OFFORM
COMMI TTEE NAME( Mus t b e same a s o n S t a t eme n t o f O r g a n i z a t i o n )
/ v d . h c c t ~~®~ ' ~~a~A 1 - e r . ~ ~ a , ~ ' ~ Se n a ~ " c Cd i ~ Y I vn ~ 7T e
NOTE : T h i s c h e du l e r e p o r t smomon ey l o a n e d t o t h e c ommi t t e e wh i c h i s d e p o s i t e d i n t h e c ommi t t e e a c c o u n t .
TOTAL UNPAI D LOANS FROM LAST REPORTI NG PERI OD $
PART 1 - MONETARY LOANS RECEI VED THM REPORTI NG PERI OD( O r i g i n a l s o ur c e o f l o a n , s u c h a s a b a n k , mus t b e sh o w n i f a t h i r d p a r t y i s
i n v o l v e d . I n c l u d e l o a n s f r o m c a n d i d a t e ' s p e r s o n a l f u n d s . )
TOTAL ( PART I ) $ 200.
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' 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 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 a n y r e l a t i v e
ma k i n g a c o n t r i b u t i o n t o t h e c o mmi 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 ) an d a f f i n i t y ( r e l a t i v e s b y m a r r i a g e ) . ( S e e Pa g e 2 o f f o r ms
p a c k e t . ) I f su r name o f c o n t r i b u t o r i s t h e same a s c a n d i d a t e , b u t t h e r e i s n o 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 umn w h e n i t a p p l i e s
PART 1 1 - MONETARY LOAN REPAYMENTS MADE TM REPORTI NGPERI OD( L o a n s f o r g i v e n must b e r e p o r t e d o n S c h ed u l e E - - I n - k i n d C o n t r i b u t i o n s . )
Page- - _ 1r s ~ , q ~ h > : . . - , . , - 1
SCHEDULE
F LOANS
( R e v . 0 8 / 9 6 ) RECEI VED
& REPA I D
0CHECK THI S BOX I F
AMENDI NG FORM
DATE
RECEI VED
( MM/ DD/ YR)
NAME AND ADDRESS OF LENDER
( I n c l u d e E n d o r s e r ' s Name, I f A p p l i c a b l e )
RELATI ONSHI P
TO CANDI DATE( I f A p p l i c a b l e ' )
AMOUNT
OF LOAN
~u I C( ~ 3 o ~ e ~ -
2 , 6 L~ 7 L ~
r o n c , ) 6 - CO
o t t ~ ( a PA
s S - ~ - ~
S
DATE PAI D
( MM/ DD/ YR)
NAME AND ADDRESS OF LENDER
( I n c l u d e En d o r s e r s Name , I f A p p l i c a b l e )
RELAT I ONSHI P
TO CANDI DATE'
( I f A p p l i c a b l e )
AMOUNT
REPAI D
Sc s 3 7
uS~
S
TOTAL CASH REPAYMENTS ( PART H) $
F r o m S c h e d ul e E - - TOTAL LOANS FORGI VEN $
TOTAL OUTSTANDI NG LOANS END OF REPORT PERI OD $ O