SEP-11-2005 09 :09 TEAMSTERS LOCAL 371 309 787 4888 P .

02

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

VERIFIED STATEMENT
514 EAST LOCUST, SUITE 104 REGISTRATION
DES MOINES, IA 50309-1912 (Out-of-State Committees)
(Rev . 08102)

I D STATEMENT REGISTRATION For office use only

(Out-of-State Committee) Comm .
Indexed
COMMITTEE NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE .
Audited
SEND A COPY TO' E BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND
ONE COPY WITHL&Wg NTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . Checked
t 'REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .
Computer
TTEE NAME
Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym .)

Mailing Address
Teamsters Local Union Na- -371 n_R_T_V_F_- 790
City, State, Zip Code Area Code Telephone No .
Rock Island . 11, 61201 - - - _C30_)781_-A_45_6_

TREASURER OTHER OFFICERS (Attach second page if needed)

Name of Treasurer Name of Chairperson
Guard "Jeep" Carns- Howard F .- Spoon
Mailing Address Mailing Address
7909 42nd Street West 7909- 42nd Street Nest
City, State, Zip Code Tele hone City, State Telephone
Bock Is land, _IL . 61201 (391187-4456 d,
~sTannCode
d IL . 61201 (309 )787-4454
IOWA RESIDENT AGENT
PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
Typed Name of Iowa Resident (Use separate page if needed to list more than one entity)
AnwarA F Spnnn Name
Mailing Address
Mailing Address
#7 Timberline Drive
Ciry State Zip Code Tel hon City, State, Zip Code
- Slue Crass , Ia. 52726 5}3P$1-1409

PURPOSE OF COMMITTEE: To support the nomination and election of canidates who will
protect and promote the interest of organized and unorganized workers and the public
een_erallv-
IOWA COMMITTEE RECEIVING CONTRIBUTION
STATE OR FEDERAL JURISDICTION WHERE COMMITTEE
IS REGISTERED OR OPERATES Committee
'~~~~
,

Board
Name of Jurisdiction
Elections
_
/ lVaa. ot. !
M iling Address

Mailing Address Dat~~~ ,,L , .~ In

If Kind Contribution, Describe
T
1020 S . Spring St . P .O_ Box 4187 a
City, State . Zip Code Tele hone Am!_~unt
Springfield, IL . 62708 10782-4141

VERIFIED STATEMENT OF COMMITTEE:

~q attest that the contribution reported above is accurate. I further attest that the information about this out-of
state committee is correct and accurate to the best of my knowledge. I attest that the reports filed in the named jurisdiction comply with requirements that are
substantially similar to Iowa Code section 56.6, including the disclosure of all contributions received and all expenditures made. I further attest that the contribution
reported above s made from an account, which does not accept contributions from corporations or other prohibited contributors under Iowa Code section 56 15.
1 understa d potential civil and criminal penalties may apply unless a signed original of this form has been filed with the Iowa Ethics and Campaign Disclosure
Board. ut-or-sttgWrPVml registered and filing full disclvaure reports in Iowa .

(Only Signature of Treasurer or Chairperson) (Title) (Date)

TOTAL P .02