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8/7/2019 Griswold John__1663__scanned
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FOR I N ST R UC T I ON S,SEE BACKOF FORM
DI SCL OSURE SUMMARY PAGECOMMI TT EENAME ( Mu st b es a m e a s o n S t a t e me n to f O r g a n i z a t i o n )
C AN DI DAT E C OMMI T T E E SONL Y :
L a t er e p o r t sa r es u b j e c tt op o s s i b l ec i v i la n d c r i m i n a lp e n a l t i e s.t h ec a n d i d a t e ,f o r ac a n d i d a t e ' sc o m m i t t e e ,a n d t h ec h a i r p e r s o n ,f o ra ` ni n d i v i d u a lr e s p o n s i b l ef o rf i l i n gt i m e l ya n d a c c ) O a t er e p o r t s.
l ~ f ~ _ w lI GNATUREOF PE HUNG REPORT
IAM F I L I N GA
( r e p o r td a t e )
[ ] CHE CK I FAMEI CMENT TOREPORTDATED
C h e c k i ft h i si s f i n a l( t e r m i n a t i o n ) r e p o r ta n da t t a c hNo t i c e o fD i s s o l u t i o nFo r m DR- 3.( Yo u mu s tc o n t i n u et of i l er e p o r t su n t i la DR- 3 i sf i l e d. )
I MPORTANT: I n d i c a t eb y #t y p eo fc o mm i t t e ey o ua r e r e p o r t i n gf o r:( 1) S t a t e w i d e l L e g i s l a t i v e ) J u d g eS t a n d i n gf o rR e t e n t i o nC a n d i d a t e( 2 ) S t a t ePA C ( 3 ) S t a t eP a r t y( 4 ) C o u n t yC e n t r a lC o mm i t t e e( 5 ) C o u n t yC a n d i t o ( 6 ) C i t yC a n d i d a t e( 7 ) S c h o o lB o a r do rOt h e rP o l i t i c a lS u b d i v i s i o nC a n d i d a t e( 8 ) C o u n t yPA A ' r . PAC ( 1 0 ) S c h o o l B o a r do r O t h e rP o l i t i c a lS u b d i v i s i o nPA C ( 1 1 1 L o c a lB a l l o tI s s u e J E
I o waC o d e s e c t i o n6 8 B. 3 2 A ( 7 )t h e rt y p eo f c o mm i t t e e ,i s t h e
REPORTFOR ( 1 )E L E CT I ONI ( 2 ) NON- EL E CT I ONYEAR .
I n d i c a t eb y #I 0
STATEMENT OF CASHONHAND
CASHON HAND a t t h eb e g i n n i n go f t h e r e p or t i n gp e r i o d. ( T o t a lo fa l lf u n d sh e l db y t h ec o m m i t t e e. T h i samount MUST b e t h es a m e a s t h ec a s ho n h an da t t h ee n do ft h e l a s tr e p o r t i n g p e r i o do r must b e z e r oi ft h i si s f i r s tr e p o r tf i l e d. ) . . . . . . . . ... . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. $
AD DTOTALMONEY TAKENI NT HI SP E RI OD
FORM
DR- 2 I DI SCLOSURE( R e v. 1 2 / 2 0 0 5 ) REPORT
F o rO f f i c eUs e O n l yComm . # )6 7L o g g e d I nS c a n n e d
Co mp u t e r
A u d i t e d -
F i l ew i t h:I o waE t h i c sa n d Ca mp a i g nD i s c l o s u r eB o a r d5 1 0 E. 1 2 " ' ,S t e. 1 ADe s Mo i n e s , I o w a5 0 3 1 9
Fa x: 5 1 5 - 2 8 1 - 3 7 0 1
I s i s a t e = ~ 1q s 1 1 0 ~ oTELEPHONE DATESI GNED
L o c a lC o m m i t t e e s ,e n t e rD a t eo f E l e c t i o n
Co u n t y& L o c a lC o mm i t t e e s ,e n t e rC o u n t yi nw h i c hE l e c t i o ni s h e l d
9 5 0 00
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9 5 0 00
F o r I n s t r u c t i o n s ,Se e B a c k o f F o r m
CONTRI BUTI ONS - - MONEY TAKEN I N( I n c l u d i n gc a n d i d a t e ' s p e r s o n a l f u n d s )
COMMI TT EENAME ( M u s tb e s ame a s o n S t a t e me n to fO r g a n i z a t i o n )
R e s e tF ar m SCHEDULEA I MONETARY
( R e v. 0 7 1 0 3 ) RECEI PTS
CHECKT HI SBOXI FAMENDI NGFORM
S TAT E CA NDI DAT ES NOT E: I F A CONTRI BUTI ONI SRECEI VEDFROMA STATE PAC ( P OL I T I C ALACTI ONCOMMI TTEE) ,L I S TTHE PAC I DENTI FI CATI ONNUMBERAND THEPAC CHECK NUMBER I NTHE DESI GNATEDCOL UMN . A L I S TOF I DNUMBERS I S AVAI LABLEFROM THE I OWAETHI CSAND CAMPAI GNDI SCLOSUREBOARD .
NOTE : ANY PERSON, OTHER T HAN AN I N DI V I DUA L ,THAT CONTRI BUTES MORE THAN $ 7 5 0 T O YOUR CAMPAI GN MAY HAVE F I L I N G
R ES PON SI B I L I T I E SAND SHOULD I MMEDI ATELY CONTACT THE BOARD .
CAUTI ON : Se ct i o n6 8 B . 3 2 A ( 6 ) ,p r o h i b i t st h e u s e o f i n f o r mat i o nc o p i e d f r o mr e p o r t sa n d s t a t e me n t s f o rs o l i c i t i n gc on t r i b ut i o nso r f o ra n y
c o mme r c i a l p u r p o s e b y a n y p er s o n o t h e r t h an s t a t u t o r yp o l i t i c a lc o mmi t t e es.
DATE P ACI DNUMBER NAMEANDADDRESSOF CONTRI BUTOR R EL AT I ON SH I P AMOUNT J I FF ORRECEI VED ( i fa p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-( MM/ D D / Y R )A ND PA CCHECK ( i fa p p l i c a b l e ) RAI SER
NUMBER I NCOMEI D#
CK# p , v. 3 a k 1 1 v os h ~ ~ ! I = SU y 3I D#
-1 1-R , ~ 7 01 5 6~
)h t ~ d j e.
1D/ 1 ~ o ~ ~ ~t ~ S . I ~ , e n n e ds t . , 5-D . a v
c K #
b r a n I ~ ~ ~ , a ~ G ~ 1 1 u ~I~ 1C1 1 6( o c ~ w . S+ s
,~ . ,. r S 1 5-6 ,I D # g L ~ - L ff. r ). r 'L v - c ~ - e e rPKC1
1 ( ~ ~ 1 G~ 0 6 CK# ~ p C S o 2~ ~ p c + f ~cr SnR
Oe~W< i 5 Fs s a 3
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FOR I NSTRUCTI ONS,SEE BACK OF FORM R e s c t o n n SCHEDULE
EXPENDI TURES B MONETARY- MONEY SPENTFROM COMMI T T EEACCOUNT ( Re v. 0 7 / 0 3 ) EXPENDI TURESSTATEPAC COMMI TT EES: NOTE: FORCONTRI BUTI ONSMADE TOSTATEWI DEOR L EGI S L AT I V E
CHECK T HI SBOX I FCANDI DATES,L I S TT HECANDI DATEI DE NT I F I CAT I O NNUMBERI NT HE DESI GNATEDCOLUMN ANDT HEPA C CHECKNUMBERFOR EACHEXPENDI TURE. A L I S TOF I DNUMBERSI SAVAI LABLEFROMTHE I OWA AMENDI NG FORMETHI CS&CAMPAI GNDI SCLOSUREBOARD.
COMMI TTE E NAME ( Mu s t b e s a m e a s o n S t a t e me n to f Or g a n i z a t i o n )
Z e E . c ; ~ - r i . UCANDI DATE NAME AND A DD RE S S TOWHOM PURPOSE AMOUNT
DATE I DNUMBER EXPENDI TURE ( DE SCR I B ETRANSACTI ON) EXPENDEDEXPENDED ( i fa pp l i c a bl e ) ( D i s b u r s e me n t )WAS MADE( MWDDI YR) AND PA C
CHECK
NUMBER
I D# / h ~3 N ~ c a S S ~ l r r l 7 i n c i Cy - S
/ U / / q / 6 6CK# l v a q 9 0 3 I t J -a ~ ~S - I - , -$ l y ~ ~ )rl - 9 0l ~ , ~~6 1 0
I D# / L o &J ~
1 D# d , - 3
I D# l GL Isl b l o ` ~ S ~ (o C' K#
Sa o H J
1 D# A' 4 , c Hi f c o o l - e C)C)1 3 0 1 Xh PL C~. c. ~ ~Y ~~ ~c a ~ s e r `
CK#
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F OR I NSTRUCTI ONS,SEE BACKOF F ORM R e s e tF o r m SCHEDULE
EXPENDI TURES B MONETARY- MONE Y SPENT F ROM COMMI TT EE ACCOUNT ( R e v. 0 7 / 0 3 ) EXPENDI TURESSTATEPA C COMMI TT EES: NOTE: F ORCONTRI BUTI ONSMADE TOSTATEWI DEOR L E GI S L AT I V E
CHECK T HI SBOX
I FCANDI DATES,L I S TT HECANDI DATEI DE NT I F I CAT I O NNUMBERI NT HE DESI GNATEDCOLUMN ANDT HEPAC CHECK NUMBER FOREACHEXPENDI TURE. A L I S TOF I DNUMBERSI SAVAI LABLEFROMT HE I OWA AMENDI NG F ORMETHI CS&CAMPAI GNDI SCLOSUREBOARD.
COMMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n to f Or g a n i z a t i o n )w o \
CANDI DATE NAME AND ADDRESST OWHOM PURPOSE AMOUNTDATE I DNUMBER EXPENDI TURE ( DESCRI BETRANSACTI ON) EXPENDED
EXPENDED ( i fa pp l i c ab l e ) ( D i s b u r s e me n t )WAS MADE( MMI DD/ YR) AND PA C
CHECK
NUMBER
I D# ' -
I D#
CK#
I D#
CK#
I D#
CK#
I D#
CK#
I D#
CK#
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FOR I NSTRUCTI ONS,SEE BACK OF FORM
COMMI TT EENAME ( M u s tb e s a m e a s o n S t a t e me n to f O r g a n i z a t i o n )
R e s e tF o r m
SCHEDULEE I N- K I N D
( R e v. 0 6 / 9 7 ) 1C ON T R I B UT I ON S
O CHECK T HI SBOX I FAMENDI NGFORM
DATERECEI VED
( MMI DDI YR)NAME AND ADDRESS
OF C ON T R I B UTO R
RELATI ONSHI PT O CANDI DATE' ( i fa p p l i c a b l e )
DES CR I P T I ONOF I NK I ND
C ON T RI B UT I ON
ESTI MATEDFAI RMARKE T
VALUE
~ I FF ORFUND- RAI SER
C ON T RI B UT I ON
_
-
J _ , ~ , r ,F .
~ C ~ i ,e , ~ tfr , r 1 TA 6 i 5 l11 ~ 76 s e t
6 s * s _ b p r $ h o - 79
F- 11 0/ l ' 7 /
\a i~N.
a d t ' I G'G k e ,: - Se l P l y -w o o~o r S~ ~ ~/0 ' r '7
~ 0 1 , 3 0 1 6
Shn E: ..
: ~. .X_ E l
F-1F- 1F-1F-1F 1
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FOR I NSTRUCTI ONS,S EE BACKOF FORM
COMMI TT EENAME( Mus tb e same a s o nS t a t e m e nto f O r g a n i z a t i o n )
NOTE: T h i ss c h e d u l er e p o r t smoney l o a n e dt o t h ec o mmi t t e e w h i c hi sd e p o s i t e di nt h ec o m mi t t e ea c c o u n t.
TO TA LUNPAI DLOANSFROM L AS T R EP ORT I N GP E RI O D$ ,: ~ * OO
PARTI - MONETARY LOANSRECEI VEDT HI SR E PO RT I N GPERI OD
( O r i g i n a ls o u r c eo fl o a n ,s u c ha s a b a n k ,mu s t b e s h owni fa t h i r dp a r t yi si n v o l v e d. I n c l u d el o a n sf r o mc a n di d a t e ' sp e r s o n a l f u n d s. )
TOTAL( PARTI ) $ ^" U
* D i s c l o s u r el a wr e q u i r e sc a n d i d a t ec o mmi t t e e st od i s c l o s e t h er e l a t i o n s h i po fa n yr e l a t i v ema k i n g ac o n t r i b u t i o nt o t h ec o mmi t t e e. R e l a t i o n s h i pm u s tb e s h o w nt ot h et h i r dd e g r e eo fc o n s an g u i n i t y ( b l o odr e l a t i v e s )a n da f f i n i t y( r e l a t i v e sb y m a r r i a g e ). I fs u r n a meo f c o n t r i b u t o ri st h esame a s c a n d i d a t e ,b ut t h e r ei s n o f a m i l i a lr e l a t i o n s h i p ,e n t e r" n o t a pp l i c a b l e "i nt h er e l a t i o n s h i pc o l u mnw h e n i ta p p l i e s.
R e s e t F o r m
PART 1 1 - MONETA RY LOAN REPAYMENTSMADE T HI SR E P ORT I N GPERI OD( L o a n sf o r g i v e nmust b e r e p o r t e do n S c h e du l eE - - I n - k i n dC o n t r i b u t i o n s. )
TOTALCASHREPAYMENTS( P A R T / / ) $"
U U
F r o mS c h e d u l eE - - T OTALLOANSFORGI VEN $ ~ ~
TOTALO UT S TA N DI N G L O AN SE N D O F R E PO RTP E RI O D $00
Page( f o rS c h e d u l eF )
SCHEDULE
F LOANS( R e v. 0 7 / 0 3 ) RECEI VED
& REPAI D
[ ] CHE CK T HI SBOX I FAMENDI NG FORM
DATE PAI D( MMI DD/ YR)
NAME A ND A DD RE S S O FLENDER( I n c l u d eE nd o r s e r ' sName,I fA p p l i c a b l e )
RELATI ONSHI PT O CANDI DATE*
i fAp p l i c a bl e )
AMOUNTREPAI D
DATERECEI VEDMM/ DDI YR
NAME AND ADDRESSO F L E N D ER( I n c l u d eE nd o r s e r ' sName, I fA p p l i c a b l e )
RELATI ONSHI PT O CANDI DATE
I fA pp l i c a b l e *
AMOUNTO F L O AN
$