FORM DR-1: Statement of Organization Form ‘Statement of 1D 13409 IDR-1 ‘Organization| Type Municipal Candidate lWeb Reporting System __ Rev. 09/2003 Status Amended For Office Use Only Name Committee To Re-Elect Jane Burleson JComm. # 13409 Indexed l»diAmended Date 9/29/2007 JAudited [Computer Committee Treasurer ‘Committee Chair Name Erin . Rial Name ‘Address 746 Exposition Drive Address Fort Dodge, 1A 50501 : Primary Ph. (515) 574-9043 Primary Ph ‘Secondary Ph. (nul) Inu-null ‘Secondary Ph. e-Mail erinrial@yahoo.com e-Mail Purpose To Re-Elect Jane Burleson as Councilperson at Large, Fort Dodge, 1A District: 0 ‘Year Standing for Election: 2007 Date of Election: 11/6/2007 ‘Candidate name & address Name Jane Burleson ‘Address 207 Central Avenuo ‘Office Sought: City Council at Large Party: Not Avallable County: Webstor Primary Bank Account Name Ciitizens Community Credit Union Address 2012 1st Avenue South Fort Dodge, IA 50501 Primary Ph. (515) 955-3014 e-Mail Account Type Checking Account Name Campaign Checkig Statement of Affirmation By Treasurer and Candidate; or Political Committees, By Chairperson STATEMENT OF AFFIRMATION: By ing this document te commits aims the flowing 1. The commitiee and al prsons connected with the commitee understand that they are subject othe laws in lowa Code chapters 68A ond 688 and the achive rue In Chapter 351 of he lowa Admnistatve Code. 2” that iowa Coce secon 684.6 and rule 381-4 9 aque the ling of csclosur reports and tha the faire to fle these repons on or before the Feaured due dates subject the cancidate or choiparson (tho caso of commiees other than @canchdate'scomnitee) 10 the automat osessmont ofa cl penalty and ho posible mpeston of other ciminal and cv sanctions 3°'thatlowa Cose secton 68A 14 and rules 151 98 tvough 443 requir the placement of the words ‘pakd fr by" and the name ofthe commiton tn a poiical materials except fr thoso toms exempted by statue or ule. 1 That lowe Code secon 68A 15 ances 351-448 trough 4.52 pron the reclp of corporate contibutins by al committees except for “iatontde ana local ballot ssue PACs. 1 candidal and a conciate's Commitee may only expend campsign funds as permits by lowa code sections 68A.40 though 68A 42 and ule Saas @. Tha the commitce wil continue te Mle closure reports unt al acy has coased, commie funds spent, debis resolved, and e fina report nd stalemont of dissolution (OR-3) has boon fle. Candidate: (signature and date) Treasurer (signature and date) IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD | S10 EAST 12th, SUITE 1A | DES MOINES, A 50319] (515) 281-4028