Professional Documents
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SIGNATURE O PERSON FILING REPORT TELEPHONE DATE
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IAMFILINGA _~ t'r . ~Y to
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(reportdate)
CAUTION : Section 68B .32A(6), Iowa Code prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .
DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT 4 IF FOR
RECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-
(MM/DD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOME
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' Disclosure law requires candidate committees to-disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the thied degree of consanguinity (blood relatives) and affinity (relatives by
marriage) . If surname of contributor is the same as candidate, but there is no Page _~ of
familial felationship, enter "not applicable" in the relationship column . (for Schedule A)
I
.Aructions, See Back of Form SCHEDULE
Reset Fomn
A MONETARY
JNTRIBUTIONS -- MONEY TAKEN IN (Rev. 07103) RECEIPTS
(Including candidate's personal funds) -
Q CHECK THIS BOX IF
COMMITTEE NAME (Must be same as oo Statement of Organization) AMENDING FORM
}-- 3
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD .
CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person olther than statutory political committees .
DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT -4 IF FOR
RECEIVED (if applicable) TO CANDIDATE' RECEIVED FUND-
(MMIDDIYR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOME
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x Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by
marriage) . If surname of contributor is the sarrae as candidate, but there is no Page `~ of
familial - relationship, enter "not applicable" in the relationship column . (for Schedule A)
FOR INSTRUCTIONS, SEE BACK OF FORM Reset Form SCHEDULE
B MONETARY
EXPENDITURES -- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev. 07/03) EXPENDITURES
STATE PAC COMMITTEES: NOTE: FOR CONTRIBUTIONS MADE TO STATEWIDE OR LEGISLATIVE
CANDIDATES, LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE D CHECK THIS BOX IF
PAC CHECK NUMBER FOR EACH EXPENDITURE. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORM
ETHICS & CAMPAIGN DISCLOSURE BOARD.
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TOTAL (iflast page of this schedule) $ ( .5~~
(for Schedule B)