FOR INSTRUCTIONS, SEE BACK OF FORM _ STATEMENT CHECK ONE: 2 Trisis aninitiar” statement of Organization fom _| ORGANIZATION or Office Use Oniy i Thisis an amended" Statement of Organization ” san ini Statoron of Organization should be filed within 10 days ofthe commitee's accepting contributions, a ‘making expendtares or neuring indabtdnees exceeding $750. Amendments shoud be Red within 30 days of@ | Cm. f ‘hange. Penatioe may bo imposed for late fed Statoments of Organization ss {Computes ‘COMMITTEE NAME = Wy ‘Shawn Ellingson For Sheriff Committee a Uy IMPORTANT: Indlcata type of commits you are reporting for: {1 )SttowidarLagiitve Candidate (2 Statewide PAC (3)Sinta Party (4 )County.ocal Candidate (5 County PAC (6 )Batot lsvelFranchise ‘Commitiee (7 )CountyCly Gentral Commitee (8 }Support slate of canddabrs (st candidates under purpose of comatie) ‘COMMITTEE TREASURER COMMITTEE CHAIR [ame Name Leisha A. Linge [Nancy A. Butterbaugh Maing Adress iiaig Aaaroes {902 South Iowa Ave. 2745 285th St. iy, Sate Zp Cade Gig, Sate Zp Cade Washington, IA. 52353 Washington, 1A. $2353 one (319 1653-7256 (work) 319-653-3107 (home) Prone (319) 653-2739 -mai,linge@federationbankia com ‘etvay Dbutterbaugh@sleuthsofiware.com INDICATE PURPOSE OF COMMITTEE ~ Check One Box [y|Advocate for/againat candidate(s) [-] Advocate forlagamnst balot suots) ‘Comment or description: Advocates for Candidate for Cotfsty Election Ghios Sauane Uli of Sheriff, Washington Cour Offtce Sought: wa ‘District; _ Political Party (# applicable) Republican ‘Year Standing for Election: 2004 : Fa I ———- como ny cr ne ae ieee na TT a a 7 Fa RET eee Shawn Eingson Fer Shariff Commitee Stave M.lingson Name of Financial Institutionype of Account — + + | Mailing Address Uy Peleus bank BDA sootena as Anes Mailing Address tT ~ | Gy ‘State FY Zp + + 102 East Main Street Washington, 1A $2353. ay oT ‘Siste 1S te TT Phone ( 319 ) 653-7502. — Washington, IA $2353 ‘eMox_lingson@iowatelecom.nct DISPOSITION OF BALANCE OF FUNDS UPON DISSOLUTION (Statement of Faant required by tow for @l comeitioon ensapt sla partis and central BPO UPONDISS Seuatdnaueley seas AES SSE ane come . 4 aoe LGOMRTATENATLPOUTOA PeTYonveeen)_()TRMRFER 19 OTER CNETIE OF THR NODATE [essences mmaraenaceica occas erento rn Try coKRAL NO PACER ie Sanne Goes nee perepace aeeecre (S) PARTISAN CONGRESSIONAL DISTRICT FUND ‘STATEMENT OF AFFIRMATION BY TREASURER AND CANDIDATE; OR POLITICAL COMMITTEES, BY CHAIRPERSON ‘Tam aware that | am requred to fie dlcosure reports the committe receives contbutions, makes expendture, or incurs ndettecness in excess of 75000 na calendar yeast expressly advocate fr ary candidate or bala esve. | Understand tat aknough the ieasurer normally prepares ahd Res reports, the candidate x chairperson (PACE) le responcte under ela Tor accurate antral leiosure reports and tht wee Rid Tepors ere subject 6(27/ 08 aie BeFORM DR-1: Statement of Organization Form ‘Statement of ID 17502 IDR-1 Organization] Type County Candidate lWeb Reporting System __ Rev. 09/2003 Status Amended For Office Use Only Name Shawn Ellingson For Sheriff Committee IComm. # 17502 Indexed Filed/Amended 1113/2004 lAucites Date [Computer Committee Treasurer Name Leisha A. Linge ‘Address 902 South lowa Washington, 1A 52353 Primary Ph. (318) 653-7256 Secondary Ph. e-Mail Committee Chair Name Nancy A. Butterbaugh ‘Address 1509 North Sixth Avenue Washington, 1A 52353 Primary Ph. (319) 653-2739 ‘Secondary Ph. e-Mail Purpose Office Sought: County Sheriff Party: Republican County: Washington District: © Year Standing for Election: 2004 Date of Election: 11/2/2004 Primary Bank Account Name Federation Bank ‘Address 102 East Main Street Washington, IA 52353 Account Type Checking Account Name Shawn Ellingson For Sheriff Commitee! Candidate name & address Name Shawn M. Ellingson ‘Address 809 North Second Ave Washington, 1A 52353 Primary Ph. (319) 653-7502 e-Mail ‘Statement of Affirmation By Treasurer and Candidate; or Political Committees, By Chairperson STATEMENT OF AFFIRMATION: By fing his document he commit aims the flowing 1. The commit and a persons connected with the commiee understand that thay are subject othe laws in low Code chapters 688 and SEE and the adinstraiv rus in Caapter 35% oe Iowa Adminitrative Code 2. That Iowa Code section 634 6 and uo 351-49 requ te ng of dielosure rears an that the fare tole these reports on or bore the rogue due cates subjects the candidate ox chairperson (inthe case of comeitensebor than a candidate's commie) tone automate ‘assessment ofa cv! penaly and onal potical mates excopt fr thoes tame exempted by stale or ule posse imposiion of other erminal and cl sanctions. 5. That iowa Code socion 684.14 and rules 351-4.98 through 443 que the placement ofthe words “pal for by" rd hername of he committee 4, Thal Lowa Code section 68A.15 and rules 351-444 trough 452 polit the receipt of corporate contibutons by all commitees except for Satowde ane ical bao issue PACS 5, A candidate and a candidate's committee may only expend campaign funds as permite by loa code sections 68A.40tyough 68A.42 andl 351425 5. That the commits wit continue t file disclosure reports until ll activity has ceased, commit funds spent debts resolved, and a nal report anda staement of asso (OR-3) has been fle. Candidate: (signature and date) IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD | 514 EAST LOCUST STREET, SUITE 104 | DES MOINES, Treasurer (signature and date) 1 50309 (616) 281-4022