c712·525·1252 •••••• (''l -.;: r::'':'...Linda J. Hoy Name PO Box 276 Richland, IA...
19
Revised 06/08 Gift or Bequest information received by a department or accepted by the Governor on behalf of the state FORM-GB IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD 510 EAST 12 TH , SUITE 1A DES MOINES, IA 50319 Fax: (515)281-4073 www.iowa.gov/ethics For office use only Indexed _ Audited _ Checked _ Computer _ Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowa or received by the Governor on behalf of the state be reported to the Iowa Ethics and Campaign Disclosure Board and the Government Oversight Committee. The Board will provide a copy of this report to the Government Oversight Committee. This form is to be filed within 20 days of receipt of the gift or bequest. DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST: DHS Glenwood Resource Center :: 1> _... ~N~a-m-e-o~f~D-ep-a-rt-m-e-n-to-r~O~ff~ic-e---------------------------------~_O=----L;~ 711 South Vine Street Glenwood, lA 51534 :::0 :z t-r :cM:-a""ili~ng---:-A....,dd-:-r-es-s-----------------~C:::ci'7""ty-,-::::S7""ta7'te-,-::::Z'7""ip-:C:::-o-d7""e--------------===--r O ::;: 712·525·1252 •••••• (''l -.;: ~~~___:_~~~---:-~----------------------------------_c Area Code & Telephone No. e r"::'':'" CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE: - Ruth Messinger Name _. Mailing Address (if different from above) [email protected] City, State, Zip (if different from above) 712-525-1683 Email Address Area Code & Telephone Number (if different from above) DONOR OF GIFT OR BEQUEST: Larry & Shirley Davis Name l306 Third Street Batavia, IA 52533 Mailing Address City, State, Zip Code 4/13/15 $10.00 Date of Gift or Bequest AmounWalue' Area Code & Telephone Number 'value is defined as "fair market value" of item as determined by receiving department or office. If no value mark "0.00". Email Address (optional) Provide a description of the gift or bequest and purpose thereof: Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center. Criteria to use this form: Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state. Statement of Affirmation: I Ruth Messinger ff th t th ift b t db' f . , a irrn a e gl or eques reporte a ove IS accurate. I urther affirm that the information concerning the donor and assessment of the fair market value (if applicable) is correct and true to the best of my knowledge. ~~~ Signature 4114/2015 Date ;::0 fT:
Transcript of c712·525·1252 •••••• (''l -.;: r::'':'...Linda J. Hoy Name PO Box 276 Richland, IA...
-
Revised 06/08
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
FORM-GBIOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics For office use only
Indexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource Center :: 1> _...~N~a-m-e-o~f~D-ep-a-rt-m-e-n-to-r~O~ff~ic-e---------------------------------~_O=----L;~711 South Vine Street Glenwood, lA 51534 :::0 :z t-r:cM:-a""ili~ng---:-A....,dd-:-r-es-s-----------------~C:::ci'7""ty-,-::::S7""ta7'te-,-::::Z'7""ip-:C:::-o-d7""e--------------===--rO::;:712·525·1252 •••••• (''l -.;:~~~___:_~~~---:-~----------------------------------_cArea Code & Telephone No. e r"::'':'"
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE: -Ruth MessingerName
_.
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Larry & Shirley DavisName
l306 Third Street Batavia, IA 52533Mailing Address City, State, Zip Code 4/13/15 $10.00
Date of Gift or Bequest AmounWalue'Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
I Ruth Messinger ff th t th ift b t db' f ., a irrn a e gl or eques reporte a ove IS accurate. I urther affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
~~~ Signature4114/2015
Date
;::0fT:
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
FORM-GBIOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood, IA 51534
Mailing Address712·525·1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Jay & Mary CowguillName
1374 Packwood Rd Packwood, IA 52580Mailing Address City, State, Zip Code 4/l3/15 $15.00
Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
*value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
I, Ruth Messinger affirm that the gift or bequest reported above is accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4/14/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 11~1~~ii8~~11www.iowa.gov/ethics .
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
DHS Glenwood Resource Center
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood, IA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
Email Address
City, State, Zip (if different from above)712-525-1683
Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Linda J. Hoy
Name
PO Box 276 Richland, IA 52585-0276Mailing Address City, State, Zip Code 4/13/15 $15.00
Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
I Ruth Messinger ff th t th ·ft b t rt db' I f ff ., a irrn a e gl or eques repo e a ove IS accurate. urther a rrm that the Information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4/1412015DateSignature
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
FORM-GBIOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics For office use only
Indexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood.Ls, 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Keith & Isabelle LeppertName
31842-320th Ave Richland, IA 52585Mailing Address City, State, Zip Code 4113115 $20.00
Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
*value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger " .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 1~~$ef~~rtn.1www.iowa.gov/ethics . -
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
DHS Glenwood Resource Center
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood, IA 51534
Mailing Address712·525·1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Steven & Lisa RobertsName
PO Box 334 Richland, IA 52585Mailing Address City, State, Zip Code 4/13115 $20.00
Date of Gift or Bequest Amount/Value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger .. . .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 I.Resetl~tt!:l!1www.iowa.gov/ethics
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM·GB
DHS Glenwood Resource Center
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood. IA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Carol Brown
Name
3002 Adams Lane Apt 2 Fairfield, IA 52556Mailing Address City, State, Zip Code 4113115 $20.00
Date of Gift or Bequest Amount/value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger .. . .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 1::R~Se~i(;l\'i~1www.iowa.govlethics
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
DHS Glenwood Resource Center
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South V ine Street Glenwood, lA 51534
Mailing Address City, State, Zip Code712-525-1252
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Area Code & Telephone Number (if different from above)Email Address
DONOR OF GIFT OR BEQUEST:
Delbert & MaryAnn NordykeName
1198 Brookville Rd Batavia, IA 52533-7622Mailing Address City, State, Zip Code 4/13/15 $20.00
Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
*value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
I, Ruth Messinger affirm that the gift or bequest reported above is accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4/14/2015Date
http://www.iowa.govlethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 1~~~~~li~ilwww.iowa.gov/ethics
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
DHS Glenwood Resource Center
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711South Vine Street Glenwood, lA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
Email Address
City, State, Zip (if different from above)712-525-1683
Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Howard & Debora AdrianName
1248 Highway 1 Fairfield, IA 52556-8956Mailing Address City, State, Zip Code 4/13/15 $20.00
Date of Gift or Bequest AmounWa1ue'Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger .. . .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
FORM-GBIOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood, IA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Carol HarringtonName
28229 Highway 78 Ollie, IA 52576Mailing Address City, State, Zip Code 4/13115 $20.00
Date of Gift or Bequest Amount/Value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:Ruth Messinger .. .
I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 1~1$lt.~~~~;1www.iowa.gov/ethics
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
DHS Glenwood Resource Center
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood, IA 51534
Mailing Address City, State, Zip Code712-525-1252
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Joe R. & Kathryn DeutschName
312 West Main Richland, IA 52585Mailing Address City, State, Zip Code 4/13115 $25.00
Date of Gift or Bequest Amount/Value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
I Ruth Messinger ff th t th ·ft b db' ., a urn a e gl or equest reporte a ove IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
\
~/L44{~k-.J 4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 1;~lil~~I~I;1www.iowa.gov/ethics -
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
DHS Glenwood Resource Center
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood, IA 51534
City, State, Zip CodeMailing Address712·525·1252
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Edith JordanName
1012 Hillcrest Drive Fairfield, IA 52556Mailing Address City, State, Zip Code 4113115 $25.00
Date of Gift or Bequest Amount/Value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger '. .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
FORM-GBIOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics
Gift or Bequest information receivedby a department or accepted by theGovemor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood, IA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
1. David & Adrian GentryName
302 Marshall Ollie, IA 52576Mailing Address City, State, Zip Code 4/13115 $25.00
Date of Gift or Bequest AmountlValue*Area Code & Telephone Number
*value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:Ruth Messinger " . .
I, affIrm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4/1412015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319:::'~i~~;!:~~~~~~SIEI$~~~~;a
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
DHS Glenwood Resource Center
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood. IA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Wayne & Kay HadleyName
301 North B Avenue Packwood, IA 52580Mailing Address City, State, Zip Code 4/13115 $25.00
Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
*value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:Ruth Messinger " .
I, affirm that the gIft or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
~~~Signatu~4
4114/2015Date
mailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 1~~s~t!Tp~11www.iowa.gov/ethics -
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
DHS Glenwood Resource Center
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood. IA 51534
Mailing Address712·525·1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Angela & Tony BondName
21337 Wapello-Keokuk Rd Hedrick, IA 52563-8502Mailing Address City, State, Zip Code 4/13115 $40.00
Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
*value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:Ruth Messinger .. .
I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 11~I~EQt~1www.iowa.gov/ethics -
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
DHS Glenwood Resource Center
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Name of Department or Office711 South Vine Street Glenwood. IA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)rrness [email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Donald & Kimberly DeutschName
24125 290th St Ollie, IA 52576Mailing Address City, State, Zip Code 4113115 $50.00
Date of Gift or Bequest Amount/Value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:Ruth Messinger . .
I, affirm that the gift or bequest reported above is accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
FORM-GBIOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood, IA 51534
City, State, Zip CodeMailing Address712-525-1252
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Harold Dickey Oil Corp
Name
Packwood, IA 52580Mailing Address City, State, Zip Code 4113115 $50.00319-695-3601 Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger " .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4/14/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics
FORM-GB
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood, IA 51534
City, State, Zip CodeMailing Address712-525-1252
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Wayne &Sylvia Horras
Name
1226 Wapello-Keokuk Rd Hedrick, IA 52563-8102Mailing Address City, State, Zip Code 4/13/15 $1,060.00
Date of Gift or Bequest AmounWalue*Area Code & Telephone Number
*value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:Ruth Messinger " .
I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
FORM-GBIOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073www.iowa.gov/ethics
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood, IA 51534
City, State, Zip CodeMailing Address712·525·1252
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
Shauna PaigeName
420 Valley Street Omaha, NE 68108Mailing Address City, State, Zip Code 4/9115 $5.00
Date of Gift or Bequest Amount/Value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Cake for Individuals residing in Unit 239 at Glenwood Resource Center
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger " .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Signature Date
http://www.iowa.gov/ethicsmailto:[email protected]
-
Revised 06/08
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD510 EAST 12TH, SUITE 1ADES MOINES, IA 50319
Fax: (515)281-4073 1:r3,~$.etl~~rilwww.iowa.gov/ethics .
Iowa Code section 8.7 requires all gifts and bequests given to any department of the state of Iowaor received by the Governor on behalf of the state be reported to the Iowa Ethics and CampaignDisclosure Board and the Government Oversight Committee. The Board will provide a copy ofthis report to the Government Oversight Committee. This form is to be filed within 20 days ofreceipt of the gift or bequest.
DEPARTMENT OR OFFICE RECEIVING THE GIFT OR BEQUEST:
FORM-GB
Gift or Bequest information receivedby a department or accepted by theGovernor on behalf of the state
For office use onlyIndexed _
Audited _
Checked _
Computer _
DHS Glenwood Resource CenterName of Department or Office711 South Vine Street Glenwood, IA 51534
Mailing Address712-525-1252
City, State, Zip Code
Area Code & Telephone No.
CONTACT PERSON FOR RECIPIENT DEPARTMENT OR OFFICE:
Ruth Messinger
Name
Mailing Address (if different from above)[email protected]
City, State, Zip (if different from above)712-525-1683
Email Address Area Code & Telephone Number (if different from above)
DONOR OF GIFT OR BEQUEST:
McGladrey LLP
Name
801 Nicollet Mall Minneapolis, MN 55402-2526Mailing Address City, State, Zip Code 4/13115 $75.00
Date of Gift or Bequest Amount/Value"Area Code & Telephone Number
'value is defined as "fair market value" of item as determined byreceiving department or office. If no value mark "0.00".
Email Address (optional)
Provide a description of the gift or bequest and purpose thereof:
Shared memorial donation for Individuals residing in Units 467 & 472 at Glenwood Resource Center.
Criteria to use this form:
Receipt of any gift or bequest that is received by any department of the state or received by the Governor on behalf of the state.
Statement of Affirmation:
Ruth Messinger " . .I, affirm that the gift or bequest reported above IS accurate. I further affirm that the information concerning the donor andassessment of the fair market value (if applicable) is correct and true to the best of my knowledge.
4114/2015Date
http://www.iowa.gov/ethicsmailto:[email protected]
