FOR INSTRUCTIONS,

SEE BACK OF FORM

CHECKONE:
I Thisis aninitiat*Statement
of Organization
Fnisisanamended*Statementof Organization
ResetForm
I t1eserF(
- >ra.ememmusr
Dert*ewm, tu aaysor@mmwee
accepang maungerpliiffi
@nmDunons,
incuning debtsexceeding$750. Amerfrmenlsmustbe filed within30 daysof a change.
EffediveJanuary1, 2010,all statements andreporlsfiledby newcommittees for siateofficemustbe filed
electronicallyand efrediveJanuary1, 2012, all slatementsand reportsfiled by all committeesfiorstateofiice
mustbe filedelectronically.
and for StatePACsand StateParliesmustbe liled

Involved in

COMTTiITTEE
TREASURER

orz" fr "5Aq>
Phone( )B /7fr4
ATEPURPOSE - CheckOneBox Advocatefor/against
candidate(s) Advocatefor ballotissue(s)
Commentor ballot
County/LocalCandidatesand Ballot lssue Gommitteeg
QfriceSought:
County:
Political Party (if applicable) (lf activein multipleballolissueelections,attachlistof counties
District: " Dateof Eleclion:
Year for Election:
or ParcntEntity (PACS.if appliceble).
Affiliate.or $oonsor

MailingAddress ,,,

City J ,1. State J J Zip +J

State Jr +r - Zio v v
Phone(

e-Mail

STATEilIEiIT OF AFFIRilATIOI{: By fillng thlc document thc commitbe afflrnrs the follwing:

1. The committeeand all per6on$connectedwith the committeeunderstandthat they are subjecito the laws in lowa Codechaptec 68A and 688 and the administrative
rulesin Chapter351 of the lowaAdministrativeCode.
2. That lowa Code section68A.402and ru16351--4.9 rcquirethe filingof disclosurereportsand that the failureto file thesereportson or beforethe requireddue dates
subjeds the candidateor chairpeGon(in the case ol committeesother than a candidates committee)to the automaticassessmentof a civil penalU and the possible
imposit'onof other criminal and civil sancfions.
3. That lova Code section 6M.405 and rules 351--4.38 through 4.43 require the placementof the words 'paid br by" and the name of the @mmitteeon all polilhal
materialsexcept for lhose items exempted by sktute or rub. A commitee that wishes to registera committeename fur purposesof using the shorter "paid for bf and
doe$ not intend to cross lhe $750 filing thresholdshall file the Form DR-SFAform in lieu of ffling fiis form.
4. That lowa Code section68A.503and rulee351-4.44 thmugh4.52 pohibit the receiptof corporatecontributionsby attcommitteesoxceptbr ballotissuePACS.
5. A candidateand a candidate'scommitteemay only expendcampaignfundsas by lowa code section$68A.301through68A.303and rule 351--4.25.
to file disdosure reports until all activity has spent, debl$ resolved,and a final report and a staterFnt ol

af rfrc
\/'g' otd
Signaturoof Candidata,OR, for all other commiltees,Chairperson