Académique Documents
Professionnel Documents
Culture Documents
4J - ';' 5213
SIGNATURE QrPEE IL1 1G REPORT ' 'TELEPHONE DATE SIGNED
n Check if this is final (termination) report and attach Notice of Dissolution Form DR-3 . County & Local Committees, enter County in
(You must continue to file reports until a DR-3 is filed.) which Election is held
"UNPAID BILLS (From Schedule D - Attach Schedule D) ..... ......... ..... ..... ........... .............. ........ ..... ... $
'IN KIND CONTRIBUTIONS (From Schedule E -Attach Schedule E) .... ..... ... ........ ..... ......... ... .. ... .....$
"OUTSTANDING LOANS (From Schedule F-Attach Schedule F) ........ ..... ... ........ ........... ... ........ .....$
CANDIDATE COMMITTEES ONLY:
CONSULTANT BREAKDOWN (Schedule G Attached?)
VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H) $
I
For Instructions, See Back of Form SCHEDULE
A MONETARY
CONTRIBUTIONS -- MONEY TAKEN IN (Rev. 0710) RECEIPTS
(hrcwding candidate's Personal funds)
CHECK THIS BOX IF
COMMP'TEE NAME (Must be same as on Statement of Organize AMENDING FORM
v
STATE C (DATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE). LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD .
CAUTION: Section 68B.32A(6). Iowa Code, prohibits the use of irlforntation copied from reports and statements for solid8ng contributions or
for any corrunerciW purpose by any person other than statutory political convrifftees.
cJ y
`,_ GK#
ID#
CK#
ID#
CK#
CK#
CK#
ID#
CK#
__
ID#
CK#
CK#
ID#
CK#
1D#
CK#
SUB-TOTAL
ID#
C K# /G
AY It-r~ err ~o
I D#
CK# a
C o
CK#,
ID# s
f d>
I D# l.
1D#
CK#
I D#
CK#
SUB-TOTAL $
Purchases of certain campaign property costing $500 or more must also be inventoried on Schedule H . (Refer to Schedule H instructions .)
Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized on
Schedule G by the amount, purpose, and date of each type of expenditure made by the person/entity on behalf of the candidate's committee. (Refer to
Schedule G instructions and Iowa Code 68A .402(3)(i) .)
(for Schedule B)
FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
E IN KIND
COMMITTEE NAME (Must be same as on Statement of Organization) (Rev. 06/97)1 CONTRIBUTIONS
~7
6 ,0
F-1
71
F-1
F-1
F]
F-1
r7
F-1
SUB-TOTAL / $
'Disclosure law requires candidates to disclose the relationship of any relative making an in kind contribution to the Page of -~
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives (or Schedule E)
by marriage). (See Page 2 of forms packet.) If surname of contributor is the same as candidate, but there is no
familial relationship, enter "not applicable" in the relationship column.
FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
NOTE : This' chedule reports money loaned to the committee which is deposited in the committee account . El CHECK THISBOX IF
AMENDING FORM
TOTAL UNPAID LOANS FROM LAST REPORTING PERIOD $
PART 1- MONETARY LOANS RECEIVED THIS REPORTING PERIOD PART 11- MONETARY LOAN REPAYMENTS MADE THIS REPORTING PERIOD
(Original source of loan, such as a bank, must be shown if a third partyis (Loans forgiven must be reported on Schedule E - In-kind Contributions.)
involved. Include loans from candidate's personal funds .)
DATE NAME AND ADDRESS OF LENDER RELATIONSHIP AMOUNT DATE PAID NAME AND ADDRESS OF LENDER RELATIONSHIP AMOUNT
RECEIVED (Include Endorser's Name, If Applicable) TO CANDIDATE OF LOAN (MM/DD/YR) (Include Endorser's Name, If Applicable) TO CANDIDATE* REPAID
MM/DD/YR If Applicable* If Applicable)
*Disclosure law requires candidate committees to disclose the relationship of any relative
making a contribution to the committee . Relationship must be shown to the third degree of
consanguinity (blood relatives) and affinity (relatives by marriage) . If surname of contributor is
the same as candidate, but there is no familial relationship, enter "not applicable" in the
relationship column when it applies. Pag e- Of -_/
(for Schedule F)