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FOR INSTRUCTIONS, SEE BACK OF FO

CHECK ONE:
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Ia This la an initial' Statement of Organization
O This is an amended Statement of Organization

'An 1nltfef Statanerlt of Organization must bill Died wMln 10 days of the pfirig tributlona,
making expendhxtlw, or incurring Indebtsdrls" exoaedf $730. Amendments 30 days of
e ahonge. Panaltles may be imposed for W*- flied St~wt o1 Organhatlon . A can an open
co+"m"ss that exceeds 5730 M activity Aor another office shell ft within 10 days either a now or arrwded
OR-1 disdwrirrg mbrtnatron aoncerrung the oempNgn for the now office sought.

COM ITTEE NAME i 1 (A candidate's committee must Include the eandidate'e last name In the name of the committee.)

77u~r-S!'l.iG I
see oomml ~ for I -
Irtg for RabnUon Candidate ( 2)SlatrMde PAC (3 )Stets Party (4 )County Central Committee
(1 )SUIbwldallAglalatlve/Judge S
(S )County CandldaIlt (ti)CRy Candldab ( 7)School Board or Other Pollrcal Subdivision Candklale (S )County PAC (9 )City PAC
(10 )School Board or Other Politlmal Subdivision PAC ( 11 ) Local Ballot Issue(Including cofrimntae Involved In multiple city/bounty ballot Issues)

COMMITTEE TREASURER _Umands" 1w all coin rfill COMMITTEE CHAIR (mandatory except for a candidate's commltfae~-

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Mailing 9ddrrss
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City, l to l 1 Z)p Code 1

Mail
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INDICA Check o nil Box

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Office Sought

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County.
Political Party (If app(Ialbble) PGf (If active In m plc llot Issue elections . attach list of counties

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Dmb Kt - Date of Election . Lto
Year Stand for EIectlon :

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Aok91 aian

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Norm of Financial Institutionnype of Aom&rtt

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Malllng Address Z 1

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City State Zip

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STATEMENT Of AFFIRMATION : By Allng this docurrient Its comrnlme affirms the fbllowsta :

1 . The comrri tne and all persons connected with the commitbs understand that they are subject to the laws in lours Code chapters 08A and 68D and the sdminlstrstivs
rules In Chapter 361 of the lows Adminlantive Coda

2. That Iowa Code section 89A.402 and rule 3'31--4 .9 require the filmy of disclosure reports and that the failure to his those reports on or before the required due dates
subjects the candid*% or "irporson (in area come of oommit"ea olhor than a cnndidate's committss) lo the sutomstic assessment of e civil penalty and the possible
impoelflon of oeier criminal and civil sanctions .
3. That Iowa Cods ooodon 8eAAM and rules351-4.38 through 4.43 require 1M Disoornsnt of the words'paid for by' and the name of the committee on all polnlcaI
rnatarisls except for those roams oxernpbd by statute or rule A corrnn*%e that wahes to rsgletsr a commltbe name for purposes of using to shortar'paid for by' and
doss not Inbred to crone t $750 filing threshold shell file the Form DRSFA form .

4 That lows Cods section 69A.503 and riles 351-4.44 through 4 52 prohibitlhs receipt of corporate cordributione by all oommitlses except for statewide and local ballot
rears PACs.

3. A candrdala and a candidate's cornfntess may only expend campaign funds to permitted by lows coda eaceons 69A .301 through 88A,303 and rule 351--4 25 .
e. That rhs commltlso will continue to file disclosure reports until all activity has cssasd, committee funds spent, debts resoMd, and a Anal report end a atatemont of
dienolugon (DRS) ho been filed

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