FOR INSTRUCTIONS, SEE BACK OF FORM FORM STATEME

CHeCR'ZSNE :
DR-1 OF
a This is an initial"` Statement of Organization (Rev 02196) ORGANIZATION
This is an amended" S atement of Organization For Offig I t e Only
An initial Statement of Organization should be riled within 10 days of the committee's accepting
Comm . #
contributions, making expenditures or incurring indebtedness exceeding 5500. Amendments should be riled
within 30 days of a change. Penalties may be imposed for late-riled Statements of Organization . Indexed
Audited
Computer

COMMITTEE NAME (Required by law) !A ETHIS &

71St;. :~v u
yt~J C bpi 1rea_su V
_-

Pi-IMPORTANT Indicate type of committee you are reporting for.

:
0 HUG - 81991
( 1 )Statewide/LegislaUve Candidate ( 2 )Statewide PAC ( 3 )State Party ( 4 )CountylLocal Candidate ( S )County PAC ( 6 )Ballot IssuelFronchiss
Committee ( 7 )County/City Central Committee ( 8 )Support slate of candidates (list candidates under purpose of

COMMITTEE TREASURER (This address used for all reminders COMMITTEE CHAIR (List additional officers on separate page)
(Required by law) and correspondence)
Name Name
C1.he
Mailing Address -
- Mailing Address

Z_ Vhi7t
City, St at Zip Code City, State Zip Code

~CJ~t ~cr O LJ`w S ZJ

Home Phone ( .Tf S) S2 Home Phone ( )

Day Phone (~(r 2_313- ~~ Day Phone ( )

PACs: INDICATE PURPOSE OF COMMITTEE

All Candidates Enter. v

Office Sought: District: Ot

Political Party (if applicable) C4 ti Year Standing for Election :

County/Local Candi s and Lonat Ballot/Franchise Committees Enter: ~,
County : Date of Election : lv9 v i` h gr~
Bank Account Name Candidate Name & Address or Parent Entity (PACs. if ag licable) .
Affllia Sponsor
~a ci~ -~ j~ J c rni d o
Name of Financial InstitutionlType of Account Mailing Address
3 2 C/ Cd `rl e~ ~t "-~A0 a liter
Mailing Address _ - City State Zip -

I` 1'H'I f ~~ c,Jti
City State Zip Home Phone ( Sid') 2 3 2 - / 1 2-,Y-
Day Phone ( fs
DISPOSITION OF BALANCE OF FUNDS UPON DISSOLUTION (Statement of intent required by law for all committees, except state parties
and central committees .)
indicate disposition of fundsby markingappropriate number in box: 171-
(1) DONATED TO COUNTY CENTRAL COMMITTEE (6) PRORATED REFUND TO CONTRIBUTORS
(2) DONATED TO LOCAUSTATE)NATL POLITICAL PARTY(undwlre one) (7) TRANSFER TO ANOTHER COMMITTEE OF THIS SAME CANDIDATE
(3) DONATED TO CHARITABLE ORGANIZATION (CANDIDATES ONLY)
(specify) (8) RETURN TO PARENT ENTITY GENERAL FUND (PACs ONLY)
(4) CITYICOUNTYISCHOOUSTATE OF IOWA GENERAL FUND (urAerlineone) (9) OTHER (PACs ONLY), PLEASE BE SPECIFIC
(5) PARTISAN CONGRESSIONAL DISTRICT FUND
STATEMENT OF AFFIRMATION BY TREASURER AND CANDIDATE; OR POLITICAL COMMITTEES, BY CHAIRPERSON
I am aware that 1 am required to rile disclosure reports if the committee receives contributions. makes expenditures, or incurs indebtedness in excess of five hundred dollars in
a calendar year for the purpose of supporting or oppose,n any candidate for public oll'rce or ballot issue. I am also aware that late-riled reports are subject to civil penalties
(fines) under the discl ro-tr1-07'o unders ugh the treasurer normally prepares and files reports. the candidate or chairperson (PACs) is responsible under the
law for accurate a timely disclos aqo inal ffirm that all committee officers have been informed of their appointment and obligations.

Date Signed

ahdidate or Chairperson (if a PAC) Date Signed