IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form U

VERIFIED STATEMENT
514 EAST LOCUST, SUITE 104 REGISTRATION
DES MOINES, IA 50309-1912 (Out-of-State Committees)
www.iowa .gov/ethic s (Rev. 07103)

VERIFIED STATEMENT REGISTRATION For office use onl

(Out-of-State Committee) Comm . #
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE .
SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND Audited
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .
THIS FORM MUST BE FILED FOR EACH CONTRIBUTI ON IN EXCESS OF $50 Computer

COMMITTEE NAME
Official Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym) .
Democracy for America
Mailing Address
PO Box 8313

Burlington, VT
Ot5$6 2State, Zip Code 181 Code 651-310%eplone No .

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
IS REGISTERED OR OPERATES (Use separate page if needed to list more than one entity)

Name of Jurisdiction Name

Federal Election Commission
Mailing Adc~r Mailing Address
999 E St ., N .W., aahington, DC 20463
City, State, Zip Code Telephone City, State, Zip Code
U

PURPOSE OF COMMITTEE

To support socially progressive & fiscally responsible candidates .

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Jeani Murray C1 1 1 -tN S FOP- 'RW1=LL-
Mailing Address
s.
Mailing Address
4400 Park Avenue #44 STMW W-J~v 1 t 14 6a616
City, State, Zip Code Telephone If In-Kind Contribution, Describe
Des Moines, IA 50321 (515 ) 306-5331
Amou t Check # Committee . ID #
, 00o . °--' 1771-//

VERIFIED STATEMENT OF COMMITTEE:

. , attest that the contribution reported above is accurate and that the information about this out-of-state
committee is correct and accurate to th best of my knowledge. I also attest that the reports filed in the named jurisdiction comply with requirements that are
substantially similar to Iowa Code se ion 68A.6, including the disclosure of all contributions received and all expenditures made . 1 further attest that the
tion reported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code
68A.15, unless the Iowa recipient committee is a ballot issue committee. 1 understand that potential civil and criminal penalties may apply unless a copy of
has_b _ file kth the Iowa Ethics and Campaign Disclosure Board within 15 days of the date of the contribution.

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