IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

VERIFIED STATEMENT
514 EAST LOCUST, SUITE 104 REGISTRATION
DES MOINES, IA 50309-1912 (Out-of-State Committees)
(Rev . 04/03)

ED STATEMENT REGISTRATION For office use only

V/ 1
(Out-of-State Committee) Comm . # V
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE.
SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND Audited
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .
Computer

COMMITTEE NAME
Official Name of Out-of-State Committee Do not abbre late pommi~ee name. Wntt I nation must be provided for Acronym) .
Tri-City Building Trades Po~itical ~ction Committe e ~~
Mailing Address
4602 46th Avenue
City, Mate, Z)R ~Vp Area Code Telephone No .
Rock Island, J, DI
(309 ) 786-1115

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)

Name of Jurisdiction Name

Illinois State Board of Elections Tri-City Building Trades Council PAC
Mailing Address Mailing Address
P .O . Box 4187 4602 46th Avenue
CiSyPState, i
g~ elg,
IL ( 2 17~e
~2on4
41
41 Rock Island, IL ity'61~Lb'p Code
62708

'URPOSE OF COMMITTEE

To educate the members of this council as to the candidates views and opinions

along with other items of concern .

DWA RESIDENT AGENT IOWA (r)FAWT;EE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Mark Meyers Lincoln for Sheriff
Mailing Address Mailing Address

1925 Fair Avenue 1024 Sp ringbrook Lane, DeWitt, IA 52742

City, State, Zip Code Telephone Date If In-Kind Contribution, Describe
Be t tendorf, IA 52722 ( 309 788-3403 9 -22-04
Amount Check # Committee . ID #
100 .00 1051

ERIFIED STATEMENT OF COMMITTEE :

i Mark Myers , attest that the contribution reported above is accurate and that the information about this out-of-state
)mmittee 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
rbstantially similar to Iowa Code section 56.6, including the disclosure of all contributions received and all expenditures made . 1 further attest that the contribution
ported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code section 56 .15. l
7derstand that potential civil and criminal penalties may apply unless a signed original of this form has been filed with the Iowa Ethics and Campaign Disclosure
yardyvjthin 15,lays of the date of thVPontribution .
Tx i-City Building Trades PAC
Chairman 9-22-04
erson submitting fo ) (Title) (Date)