Please Complete ALL Blanks

FORM
FOR INSTRUCTIONS, SEE MANUAL STATEMENT
DR-1 CC OF ORGANIZATION
Check One : -' C A NOIDATE
This is an Initial' Statement of Organization f' - _. . . .
For office use only
o This is an Amended' Statement of Organization , ~- , ..
'A new Statement of Organization should be filed within 10 days Jf the comfnlttee`.s accepting-contributions, Comm . 8
Indexed ~-
making expenditures or incurring indebtedness exceeding $250 - in the aggregate . Amendments should be
Audited
filed within 30 days of a change . tike. 1992 MAR 12 11 : 55
Checked
Computer

CANDIDATE COMMITTEE NAME

Official Name of Candidate Committee (Identify acronyms. Last name of candidate should be part of official name .)

.TAM ISom I'pk Au-a rmit

Mailing Address of committee if a separate headquarters is established .

City
. 0 Ll s r'!1111! Rol
State Zip Code Area Code Telephone

A .Sooj 0 :;3a - iia!'

-
COMMITTEE TREASURER (This address used for all reminders & correspondence) COMMITTEE CHAIR (List other officers as requited by law on back of form)

Name Name
Qoued l: LI Nf 8 t.iAAIE /JIMfso.v
Mailing Address Mailing Address
III S % /~ S'T 917 s. &E&rNFa v dZF -0,1l d
City, State Zip Code Area Telephone City, State Zip Code Area Telephone

&VA
dT .T.4 5'Q = Code
d rnL ARI,d . MA ISIS/.St~ - codes-
-may
FINANCIAL INSTITUTION IN WHICH FUNDS ARE DEPOSITED

Candidate Committees are required by law to deposit all funds and pay all bills from a separate account, and to disclose the name of the financial institution
where funds are deposited. Use back of form If more than one . Exception : If all campaign expenses will be paid from personal funds and no donations
will be accepted, separate account not required .

Name of Financial Institution (Bank, Savings d Loan, Credit Union, etc.)

Mailing AddressI Name as wn on account and checks

fk. f (J s rDR
City State Zip Code Type of Account (checking, savings, certificate of deposit, etc .)

CANDIDATE SUPPORTED
Name of Candidate Office Sought County

' k , _ u ii I\l _
Address (Home) Political Part- (Democrat, Republican, Lldependent, etc . Year Standing for Election

Ay a2
tol
.
C
City State Zip Code Area Code Telephone

ot
DISPOSITION OF BALANCE OF FUNDS UPON DISSOLUTION

All candidates are required to make a statement of intent of how leftover funds would be expended at the close of the campaign when
the committee is dissolved . This statement may be amended at a later date if the candidate chooses . The statement must be made,
even if the candidate anticipates there will be no leftover funds . The choices listed below are the ONLY legal options.

CHECK ONE AND ENTER SPECIFIC NAME:

O Donate to Local Political Party 0 Return Prorata to Contributors
Donate to STt ;'XY EMMXUGdrtl County Central Committee 0 Transfer to State of Iowa General Fund
Donate to State Political Party 0 Donate to
(Specify Charitable Organization)
0 Donate to National Political Party
11 Donate to
(Specify Candidate's Committee)

STATEMENT OF AFFIRMATION BY TREASURER AND CANDIDATE

I am aware that disclosure reports are required if the committee and/or candidate receives contributions, makes expenditures, or incurs
indebtedness in excess of two hundred fifty dollars in the aggregate in a calendar year for the purpose of supporting or opposing any
candidate for public office. I am also aware that late filed reports are subject to civil penalties (fines) under the disclosure law. I also understand
that althougts4he-heasurer normally prepares and files reports, the candidate is responsible under the law for accurate and timely disclosure
reports.

19
Dale Signed