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I MPORTAN I n d i c a t e b y A t y p e o f c o mmi t t e e y o u e r g r e t R t n a r o r( 1 ) S t a t e w d a l L e g l s l a t i v e l ! u c g e S t a r d l n g f o r Re t e n t i o n C a n d i d a t e ( 2 S PA C ( 3 ) S t a t e Pn y( a ) C o u n t y C e n t r a l C o mmi t t e e ( b ) C o u n t y C a n d i d a t e ( 8 ) C i t y C a n d i d T t q ( , ) S c h o o l B o a r d o r Ot h e r P o l i t i c a lS u b d l v l s l o n C a n d i d a t e ( 8 ) C o u n t y FAC ( 9 ) C i t y PAC ( 1 0 ) S c n d o t B g a t d o r O t h e r P o l l l l c : a ! S u b o l v l s i o n PA C1 1 ) L o c a l B a l l o t I s s u eCANDI DATE COMMI TT EES ONL Y :

e n d i d a t e Name A o l i t i r a l P a r t y ( i f a p p l i c a b l e - )r e

L a t e r e p o r t s a r e s u b j e c t t o p o s s i h l e c i v i l e n d c r i mi n a l p e n a l t i e s . P u r s p a r d t o I o w a C o d e s e c t i o n 6 88 3 2 A ( 7 ) t h e c a n d i d a t ea n d t h e c h a i r p e r s o n , f o r a n y o t h e r t y p e o f c o mmi t t e e . I s t h e i n d i v i d u a l l r t l l s A o n s i b l e f o r f i l i n g t i me l y a n d a c c u r a t e( Ok+ t - 7 1 1 4

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ST A T EMENT OP CA SH ON HANDCASH ON HAND a t t h e n e gmn i n g o f t h e r e p o r t i n g p e r i o d ( T o t a l o f a i l f u n ds h e l d b y t h ec o mmi t t e e T h i s amoun t MUST b e t h e s ame a s t h e C a s h o n h a n d a t t h e e n do f t h e l o 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 r i l e d . ) - . . . . .

ADD TOTAL MONEY TA K E N I N T HI S PERI ODS c h e d u l e A . Ca sh C o n t r i b u t i o n s t o t a l ( A t t a c h S c h e d u l e A ) ( ' a l s o s e e i n - k i n d b e l o w ) . . . . . . . . . . .S c h ed u l e F L o a n s R e c e i v e d t o t a l ( A t t a c h S c h e d u l e F ) . l . . . . . . . . . , . . . , . .S c h e d u l e H , T o t a l S a l e s o f Camp a i g n P r o p e r t y ( A t t a c h $ c h e d u l e H ) . . ,

( Sc h e du l e H a p p l i e s t o C a n c i l d a t t e s ' Co mml ISUB- TOTA L . . . . . . . . . . . . . a

SUBTRACT TOTAL MONEY SPENT T HI S PER I ODS c h e d u l e B E x p e n d i t u r e s t o t a l ( A t t a c h S c h e d u l e 8 ) ( " a l s o s e e d e b t s a n d l o a n s b e l o w ) .S c h e d u l e F L o a r Rep aymen t s t o t a l ( A t t a c h S c h e d u l e F ) . . .

CASH ON HAND e t t h e e n , ; o f t i n s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t I ? a l a n c e m u s tb e c a r e ) Wi t a : h D R- 2 ) . . . . , . . . . . . . . . . ." ' UNPAI D BI L L S ( F r o m S r h e d i l e D - A t t a c h S c h e d u l e 0 ) . . . . ; . . . .' I N K I ND CONTRI BUT I ONS ( F r o m S c h e du l e E - A t t a c h S c h e d u l e , E l l . . . . , ." OUTSTANDI NG L OANS ( F r o m 3 c h e d u l o F - A t t a c h S c h e d u l e F ) . . . . . . . , .CONSUL TA NT B REA KDOWN ( S c h e d u l e G A t t a c h e d ? ;QI NDI DATECOM1i i QN L Y;VAL UE OF CAMPAI GN PROPERT Y ( F r o m S c h e d u l b H - A t t a c h 4 a he o u l e H )STATE COMMI TT EES ; S u b mi t a r e r o n c l l e d c a mp a i g n a c c o u n t b p n k s t a t e me n t i n J a n u a r y o f e a c h y e a r .

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C O M M I T T E E N A M E ( A . l u . s t D e s a m e a s a n S t a t o m o n r o r O r y , 1 1 0 1 4 1 1 1 M o n 1 U M E N D T C 5 B O . C I FA E I N G : F O R Mh t O t t 1 Y - f$TAT? CUNI NDATES NOTE : I F A CGN' I I B I ; TI ON I S RECEI VED FROM r { 1 / AT-- - PAC ( P - , ) ; I - I C A L A i ; T , ON COMMI TTEE L I ST " H E PAC I DEN? I F i CATi ONNUMSER, AND THE PAC CHECK NI - MSER N T O ~ g DESI GNATED COL UMN 0 WST OF I D NUMSERS 1 3 AVAI LABLE FROM T4 E I OWA ETHI CS AND CAMOAJ GNDI SCL OSURE SOAROCAUTI ON : Se c t i o n 3 0 8, 3 ; A' E1 l o e a C f ) d e , wo h l b l t s t h e u s e o f I r f mp bo n c o p i e c 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 , s o t i d t l n g c o nt r , b u t i o n s o rf o r a n y c o mme r c i a l p ur p o : @ b y a n y p a r s o n c > t n e r t h an s t a t u t o r y pol l t o r n r i t t e e a

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STATE CANDI DATES NOTE : I F A CONTRI BUT I ON I S RECEI VED FROM A STATE PAC ( P O L I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I DENT I F I CATI ONNUMBER ANDTHE PACCHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LABLE FROM THE 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 l r Oo l t m a t i o n c o p 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 an y c o mme r c i a l p u r p o s e by 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 ; Uco l c o mmi t t e e s .

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TOTAL ( ! f l a s t p a g e o f t h i s s c h e d u l e )D I B G o > 9 u r e l a w r o q u l r e n Ce nd I OS t A c o mmi t t g wc 1 0 d i s c l o s e t h e r e l a t i o n s h i p a t J m r e l a t i v e m a l c I n g e c o n t r i D u l i o n 6 7 t h ec o mmi t t e e . R e l a l l o n s h l p must b e s h own 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 d r e l a t i v e s ) a nd a f f i n i t y ( r e l a t i v e s by

ma r r i a g e ) . I ( s u r n a me o f c o n t r i b u t o r i s t h e s a m e a s c a n d i d a t e , b u t t h e r e + s nof 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 u mn .

SCHEDULEA MONETARY( Re v 0 7 1 0 3 ) RECEI PTSQCHECK T HI S BOX I FAMENDI NG FORM

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STATE PAC COMMI T T EES : NOTE : FOR CONTRI BUTI ONS MAD~ TO STATEWI DE OR L E GI S L A T I V ECANDI DATES, L I S T THE GANDI DATE I D E N T I F I C A T I O N NUMBER WTHE DESI GNATED COLUMN AND THE CHECK T HI S BOX I FPAC CHECK NUMBER FOR EACH 5XPENOI TURE . A L I S T OF I D N4NNLRS I S A V AI L A B L E FROM T HE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD .COMMI TTEE NAME ( M u s t b e s am e e . s o n S t e t e m e n t o ( O r g n ~ z s t i o n )

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