IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

VERIFIED STATEMENT
510 EAST 12th, SUITE 1A REGISTRATION
DES MOINES, IA 50319 (Out-of-State Committees)
www .lowa.gov/ethics (Rev . 07103)

IED STATEMENT REGISTRATION For office use only

(Out-of-State Committee) Comm . #
Indexed
EES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE .
O THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND Audited
CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION. Checked
EASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .
THIS FORM MUST BE FILED FOR EACH CO NTRIBUTION IN EXCESS OF 350 Computer

COMMITTEE NAME
Official Name of Out-of-State Committee (Do not abbreviate committee name. Written explanation must be provided for Acronym) .
Campaign of One Political Action Committee
Mailing Address
P .O . Box 887
City, State, Zip Code Code ephone No.
Ames, IA 50010 355-84

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)

urisdiction Name
Federal Election Commissiion None
Mailing Address Mailing Address
999 E St. NW
Tele Te City, State, Zip Code
Ras WA T50e20463 ) 694-1100

PURPOSE OF COMMITTEE

Campaign of one brings the personal democracy movement to the Republican party . It aims to inspire volunteers

to become political entrepreneurs and take their message to people within their spheres of influence .

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Carol Earnhardt Machacek for Linn County Supervisor
Mailing Address Mailing Address
1748 E . 43rd St. 4414 N . Alburnett Rd ., Alburnett, IA 52202

City, State, Zip Code Telephone Date If In-Kind Contribution, Describe

Davenport, IA 52807 (5 63 ) 35 5 -8430 10/20/2004 supporter mail ing
Amount Check # I Committee . ID #
$ 88 .00

VERIFIED STATEMENT OF COMMITTEE :

1 R"Oe r- L IM K , attest that the contribution reported above is accurate and that the information about this out-of-state
committee is correct and accurate to the best of my knowledge. 1 also attest that the reports filed in the named jurisdiction comply with requirements that are
substantially similar to Iowa Code section 68A.6, including the disclosure of all contributions received and all expenditures made . I further attest that the
contribution reported above was made from an account that does not accept contributions from corporations or other prohibited contributors under Iowa Code
section 68A.15, unless the Iowa re committee is a ballot issue committee. I understand that potential civil and criminal penalties may apply unless a copy of
this form has been filed with th owa Ethi s and Campaign Disclosure Board within 15 days of the date of the contribution .

- TEA-s'u2~R 2!o Oer 2_0a4

(Pers ubmit(ng form) (Title) (Date)