TO :15152814073 P .

2/4
5152615609
SEP-i_"7-2007 16 :10 FROM :DELTA DENTAL OF IOWA

FOR INSTRUCTIONS, SEE BACK OF FORM ETHICS AND

" ,. C, `IA
' -.
HECK ONE'. f,
This is an initial" Statement of Organization
fJ This IS an amended Statement of Organization 2001 (, 2 7 P 1.1 4
SE-
initfal Statement of Organizadon must be Algid w0hin 10 days of the commWee's accepting contributions,
~ng expendiwes, orincuninp indobfodness erceedfng 1750. Amendrnenta must loo firedwfM 30 days of
. alange. Penalties maybe irnoosed for)a*&d Statements ollOrganizabon. A conddato with an open
oommiftee that exceeds $750 in acBvr?y loranoAhvr ofoe shall ft wr7hn 10 days eidwr a rlew or amended
DR-1 discloskig information concerning the campaign for Me new o/Fce sought.

COMMITTEE NAME 1 1 (A candidate's cormnittoe must include the candidate's last name in the name, of the convnifec.)

I Political Action Committee

typo of commilbse you an rape rigor

(1 )SGroolvldeft er1ativeiiJudge Standing for Retention Candidate ( 2 )Statiwido PAC ( 3 )state patty (4 )County Conceal Committee
(b )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Political Subdivision Candidate (II )County PAC (9 )City PAC
(10 )School Board or Othor Political Subdivision PAC (11) Local Ballot Issue(including committee involved in multiple Cityfcounty ballot Issues)

manda for all committoos) COMMITTEE CHAIR (mandn"except for acandidate's committee
Name T

Mailing Address 1
240),_SE TnnAS Dr_ ) 13
City. state
1Ankeny;~Al y50021
Phone (515) 96-55669 Phone (515) 261-5575

e- MUl CHard DeltaDq e-Mail DHutchins@DeltaDentalia .com

61-CAX Advocate fotyagainat candidate(s)
Advocate forballot issue($)
Comment or desertion © Advocate inst ballot issue s
Al an tats , CountylLoca a and oval Bs mrnittoos enter
Office Sought-
County: -
Political Party (if applicable) _ (if active In multipleballot issue e
~dions, attach list of coxtfies
District: - Date of Elowon :
Year Standing for Election.
. : Aec,~Namo

Delta Dental of Iowa PAC

Name of Financial Instituiortype of Account

-BankersTrust Z4Q1 SE Tones Dr # 13

Mailing Address 1 1 City State 1 1 7,tp
Ankeny, IA 50021
Pww (515) -261-5500

STATEMENT OF AFFIRMATION: By flllng this document the comrnittoo affirms the following;

1 nee committeeand aU P9fWSCOnrrocted with ttornrnittee understand that tt1ay are supled to "WO" in Iowa Code chapters 68A and 6613 and the adrrtiniwativo
rues inn Chapter351 of the low* Administrative Code
in-
2 That Iowa Code section ea11402an0 rule 351-4 .9 require thefiling of disdosure reports and tnat the failure to file rapper$ on or belom the required duo ones
"COB the candidate or chaitporsm (in the case of ownrrtlttew other than a candidate's comrnine) to the wtOmatiO asscssnwt of a civil penalty And the possible
imposition of other afninal and Crw1 sanctions
3 That Iowa Code section 68A 4QS and rules 351-4.38 through 4 43 More the placement of thewords "paid forby' and the name of that couinlidee on all political
materials except for thoseitems pxemphfd by statute arule . A oontrnittee that wishes do register a committee name for purposes of using the shpner'pai0 for by' and
does not intend to cross the $750 filing threshold shall file the Form DR-SrA tam.
4 That Iowa Code section 08A.803 andrules 351- 44 9wough 4 52 prohibitthe receipt of crirportle Contributions by all COMMIRoas except forStatewide and local tallut
issue PACs

5 A candidate and a candidate's committee moy sty expend Glm00 funds as pamttted by Iowa code sections 6M 301 through 66A 303 and (Ule, 361-425
6 1 totIfto conwrtilk¢ will continue 10 lie disdosurp reports until all activity has ceased, camrnittilift funds spent, debts rgsolvod . and a renal rgpxl ono a statement of
dissolution (DR-3) has tgeen Plod,