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8/7/2019 Sokolowski Dick__1548__scanned

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FOR I NSTRUCT I ONS, SEE BACK OF FORMDI SCLOSURE SUMMARY PAGECOMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f O r g a n i z a t i o n )

o k o ) o ws k - C o i - S - t e x f - c s ~ ~ e C o r n r n i ' f f - t - cI MPORTANT : I n d i c a t e t y p e o f c o mmi t t e e y o u a r e r e p o r t i n g f o r :( 1 ) S t a t e w i d e / L e g i s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P ar t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e( 5 ) C o u n t y PAC ( 6 ) B a l l o t I s s u e / F r a n c h i s e C o mm i t t e e ( 7 ) C o u n t y / C i t y C e n t r a l C o mm i t t e eCANDI DATE COMMI TTEES ONLY" 'Ca n di d a t e Name

J t * l 2 i ; l . U i J V tO f f i c e S o u g h t D i ~ t r i c t ( i f Se n a t e o r H o u s e )

SUBTRACT TOTAL MONEY SPENT T HI S PERI OD

kP d ) i t i c a l P a r t y

SI GNATURE OF t hEASURER ( o r p e r s o n f i l i n g t h i s r e p o r t ) TEL EPHONEL a t e f i l e d r e p o r t s a r e s u b j e c t t o p o s s i b l e c i v i l a n d c r i m i n a l p e n a l t i e s .

SEE I NSTRUCT I ONS ON BACK AND COMPLETE THE FOLL OWI NG SENTENCE :I AM F I L I NG A o C + 0 6 , - ( - ) 5 4 - , - REPORT FOR AN/ A ( 1 ) ELECTI ON / ( 2 ) NON- E LECT I ON YEAR .

( r e p o r t d a t e )CCHECK I F AMENDMENT TO REPORT DATED

I n d i c a t e o n e

[ ~ C h e c k i f t h i s i s f i n a l ( t e r m i n a t i o n ) r e p o r t a n d a t t a c h N o t i c e o f D i s s o l u t i o n Fo r m DR- 3 .( Yo u mus t c o nt i n u e t o f i l e r e p o r t s u n t i l a N o t i c e o f D i s s o l u t i o n i s f i l e d . )

STATEMENT OF CASH ON HANDCASH ONHAND a t t h e b eg i n n i n g o f t h e r e p o r t i n g p e r i o d . ( T h i s i s t h e t o t a l o f a l l mo n i e s h e l d

b y t h e c o mmi t t e e . T h i s amo u n t MUST b e t h e s ame a s t h e c a s h o n h a n d a t t h e e n do f t h e l a s t r e p o r t i n g p e r i o d , o r mu s t b e z e r o i f t h i s i s f i r s t r e p o r t f i l e d . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ADD TOTAL MONEY TAKEN I N T HI S PERI ODSc h e du l e A : C a s h C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e du l e A) ( * a l s o s e e i n - k i n d b e l o w) . . . . . . . . .Sc h e du l e F : L o a n s Re c e i v e d t o t a l ( A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e du l e H : T o t a l Sa l e s o f Ca mp a i g n P r o p e r t y ( A t t a c h Sc h e du l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( Sc h ed u l e H a pp l i e s t o Ca n d i d a t e s ' Co mmi t t e e s On l y )SUB- TOTAL . . . . . $

Sc h e du l e B : Ex p e nd i t u r e s t o t a l ( A t t a c h Sc h e du l e B ) ( * * a l s o s e e d e bt s a n d l o a n s b e l o w) . . . .Sc h e du l e F : L o a n Re p a y me n t s t o t a l ( A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CASH ON HAND a t t h e e n d o f t h i s r e p o r t i n g p e r i o d ( i f f i n a l r e p o r t , b a l a n ce mus tb e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

FORMDR- 2 DI SCLOSURE( Re v . 0 7 / 2 0 0 3) REPORTF o r O f f i c e Us e O n l yCommL o g g e d I n -- s L - - - - - - - - - - - _ -S c a n n e dCompu t e r - - - - - - - - - - - - - - __-A u d i t e d

L o c a l C o mm i t t e e s , e n t e r Da t e o f E l e c t i o nCo un t y & L o c a l C o mm i t t e e s , e n t e r Co u n t y i nw h i c h E l e c t i o n i s h e l d

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-5/ 36- 0~_ 3 1 - 3 - T o q5_ _ _ __

* * UNPAI D BI L L S ( F r o m Sc h ed u l e D - A t t a c h Sc h e du l e D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ - - -* I N KI ND CONTRI BUTI ONS ( F r o m Sc he d u l e E - A t t a c h Sc h e d u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ - - - - - -q&, F , -oQ- - - - - _ __* * OUTSTANDI NG LOANS ( F r o m Sc h ed u l e F - A t t a c h Sc h e du l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _ _ _D-______CANDI DATE COMMI TTEES ONLY :CONSULTANT BREAKDOWN ( Sc h ed u l e G At t a c h e d ?) DYESVALUE OF CAMPAI GN PROPERTY ( F r o m Sc h ed u l e H - A t t a c h Sc h e du l e H) $ _-0- - - - - - - - - - - - - - - _ _ _


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Fo r I n s t r u c t i o n s , See Back o f Fo r mCONTRI BUTI ONS - - MONEYTAKENI N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e men t o f Or g a n i z a t i o n)t 54~/ ~, w~k~ ) CPo t ' PSce; MI oe C' o mmI ' Hee_

Rese t Fo r m

SUB- TOTAL

STATE CANDI DATES NOTE : I F A C ON T R I B U T I ON I S R E CE I V E D FROM A S TA TE PAC ( P OL I T I C A L A C T I ON C OMMI T T E E ) , L I S T THE P A C I D E NT I F I C A T I ONNUMBER AND T HE PAC CHECK NUMBER I N T H E D ES I GN AT E D COLUMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM T HE I O WA E T H I C S AND CAMPAI GND I S C L O S UR E BOARDCAUTI ON : S e c t i o n 6 8B . 3 2 A ( 6 ) , I o wa Co d e, p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c o mmer c i a l p u r p o s e by a n y p er s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e es

$aTOTAL ( i f l a s t page o f t h i s s c h ed u l e )

* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h ec o mmi t t e e . R e l a t i o n s h i p mu s t b e s how n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b yma r r i a g e ) . I f s u r n a me o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n o P a g e t o ff a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r Sc h e d ul e A)

SCHEDULEA MONETARY( Re v . 0 7 / 0 3 ) RECE I PTSCHECK THI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESSOF CONTRI BUTOR RELAT I ONSH I P AMOUNT 4 I FR ECE I VE D ( i f a p p l i c a b l e ) TO CANDI DATE * R ECE I V ED FUN( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAINUMBER I NC

CK# y l y d . ( e eMec CZ 1 1 6 _ S / u 3 ?I D# T o rAQ ' L I PA~a- ~ r l d_ l l r fCK# S k 3 S f ) ~ e 0 0I D# k d r l t " d Ao r ' L 6 - ; ' c k

L e I n a r S 5 1 c ) 3 ) L ~ . C ) L ?I D# . j e - ~ - F , 4 7 l t d Si n d 1 , n L

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3/14

Fo r I n s t r u c t i o n s , Se e Back o f Fo r mCONTRI BUTI ONS - - MONEY TAKEN I N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEENAME ( Mu s t be s ame a s o n S t a t e me n t o f Or g a ni z at i o n). Jo k oAw_ r ; Kt . 4c S- f e- i l e

STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I D EN T I F I C AT I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s an d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r any c omme r c i a l p u r p o s e b y any p er s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e es .

SUB- TOTALTOTAL ( i f l a s t p a g e o f t h i s s c h e du l e )

* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mmi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h ec o mmi t t e e . R e l a t i o n s h i p mu s t b e shown t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b yma r r i a g e ) . I f s u r n ame o f c o n t r i b u t o r i s t h e same a s c a n d i d a t e , b u t t h e r e i s n of a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l umn ( f o r Sc h e d ul e A )

SCHEDULEA MONETARY( Re v 0 7 / 0 3 ) RECEI PTS

CHECK THI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSHI P AMOUNT 4 IRECE I VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECE I VED FU( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RANUMBER I NI D# 7~ a f ' i l O Pr 1 l h a r &~ -CK# q3437 C- ( p O

- , 3 0 r OS ,I D# I F r G n c , S n~ o t 3G x a ~ 1

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c rf"%I D# ( S re g eCK# 70 SO575 ~ v r )I D# F r P c l K ; r s ' ~ Pi t f c t n nWC a r k 1 L 4 1 ' Lq- 0 3 ` - 0 4 c K# ~ ~ c '

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Fo r I n s t r u c t i on s , See Ba c k o f Fo r mCONTRI BUTI ONS - - MONEY TAKEN I N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEENAME ( Mu s t b e s ame as on S t at e me n t o f O r g a n i z a t i o n )l r k n . wSkl o 4 0 ' f -STATE CAND I DATES NOTE : I F A C ON T RI B U T I O N I S R E CE I V E D FROM A S T A T E PAC ( P O L I T I C A L A C T I O N C OM MI T T E E ) , L I S T THEPAC I D EN TI F I CA T I ONNUMBER ANDT HE P A C CHECK NUMBER I N THE D E S I G NA T E D COLUMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I O WA E T HI C S AND CAMPAI GND I S C L O SU RE BOARD .C AU T I ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa C o d e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s an d s t a t e m e n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a n y c o m m e r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mm i t t e e s .

S UB- T O T A LTOTAL ( i f l a s t p a g e o f t h i s s c h e du l e )

* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h ec o mm i t t e e R e l a t i o n s h i p m u s t b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b ym a r r i a g e ) . I f s u r n a me o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n o P a g e _ , o ff a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u m n . ( f o r S c h e d u l e A )

SCHEDULEA MONETARY( R e v 0 7 1 0 3 ) RECEI P T S

CHECK T HI S BOX I FAMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRES S OF CONTR I BUTOR RELAT I ONSHI P AMOUNT 4 IRECEI VED ( i f a p p l i c a b l e ) T O CAND I DATE* RECEI VED FU( MM/ D D/ Y R) AND PAC CHECK ( i f a p p l i c a b l e ) RANUMBER I NCI D# Kr r S ~OC~ r n ' 1 ~ t t _CK# 1 , ; 9 3 c t t l , ~ x S ' r t 4 5: OoAmes . , - - A 5 - 0 0 1 0I D#C K# Ch i h J 1 a 1 j d/ 07` f i r o f ~ ? D c EI 1 t O r 1r ? r c l C lI D# i 3 c t f - U, G t r t ~ R t ~ r - K e _ r n S 'q CK# 8 1 3 Ar mo r cI D# 1 1 " o r m c t i k 4 A A uCK# 1 3 a I C CO, C , ' r i c r 1 9 0 e -S l y r - 5 0 .I D# ~ ~ ~ c ~ t p c t S + u b b c- CK# 7OC a t , , 1 CJ r y L

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Fo r I n s t r u c t i o n s , . Se e Ba c k o f Fo r mCONTRI BUTI ONS - - MONEYTAKENI N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t emen t o f Or g a n i z a t i on )

STATE CANDI DATES NOTE : I F A CONTR I BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I D E NT I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : S e c t i o n 68 B . 3 2 A ( 6 ) , I o wa Co d e, p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n d s t a t e me nt s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r a ny c ommer c i a l p u r p o se b y a ny p er s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e es .

SUB- TOTALTOTAL ( i f l a s t page o f t h i s s c h ed u l e )

* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mmi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h ec o mmi t t e e . R e l a t i o n s h i p mu s t b e s h ow n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b yma r r i a g e ) I f s u r n a me o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n o P a g e~_o ff a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r Sc h e d u l e A)

SCHEDULEA MONETARY( Re v 0 7 / 0 3 ) RECE I PTSQCHECK T HI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT 4 I FRECE I VED ( i f a p p l i c a b l e ) TOCANDI DATE* RECE I VED FU( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAINUMBER I N1 - ~ - Uy - I D# 1 ~ I U o r - i Wes t 1 - ow& L c 1 b o r C o ' : i l e ; 1

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1 9 4 CK# C h f ; s W ' y ' P r - s ( - , - - l L 7 , 0 0i ~ q . 5 404 s t C1PqrLj kt ? _ _ f i q -S059&I D# / t i n n y c l nd Fl orence 61- coks

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I D# F1Pan i ggrr . So k


6/14

Fo r I n s t r u c t i on s , Se e Ba c k o f Fo r mCONTRI BUTI ONS - - MONEY TAKEN I N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEENAME ( Mu s t b e s ame as o n S t a t e me n t o f O r g a n i z a t i o n )JOk o ( o v ) s ~ ; - Far f f e t f P Ex r e S f wAe i ~l ; t ) t Cknr n1 ` ` l T 0 _ _

R e s e t Fo r m SCHEDULEA MONETARY( R e v . 0 7 / 0 3 ) I RECEI PTSCHECK T HI S BOX I FAMENDI NG FORM

STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P O L I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I D E NT I F I C A T I O NNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se c t i o n 6 8 B . 3 2 A ( 6 ) , I o wa Cod e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r om r e p o r t s an d s t at e me n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o rf o r an y c o mme r c i a l p u r p os e b y an y p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

SUB- TOTALTOTAL ( i f l a s t page o f t h i s s c h e du l e )

D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o m mi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a c o n t r i b u t i o n t o t h ec o mmi t t e e . R e l a t i o n s h i p mu s t b e s h ow n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b yma r r i a g e ) . I f s u r n ame o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n o Page 5f a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l umn . ( f o r Sc h e d ul e A)

DATERECE I VED PA C I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELAT I ONSHI PTO CANDI DATE" AMOUNTRECEI VED 4 I FkU( i f ap pl i c ab l e )( MM/ DD/ YR) AND PA C CHECK ( i f a pp l i c a b l e ) RANUMBER I NCI D# f -0-9 ~~~r t d I QM~CK# j o - 7 0 i ' ~ . Str t i $ Q OCR

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7/14

Fo r I n s t r u c t i o n s , Se e Ba c k o f F o r mCONTRI BUTI ONS - - MONEY TAKEN I N

( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t emen t o f O r g a n i z a t i o n )

SCHEDULEA MONETARY

( R ev . 0 7 / 0 3 ) RECEI PTSQCHECK THI S BOX I FAMENDI NGFORM

STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMASTATE PAC ( POL I T ICAL ACTI ON COMMI TTEE) , L I S T THE PAC I DENTI F I CATI ONNUMBER ANDTHE PAC CHECK NUMBER I N THEDESI GNATED COLUMN . A L I S T OF I D NUMBERS I S AVA I LAB LE FROMTHE I OWA ETHI CS ANDCAMPAI GNDI SCLOSURE BOARDCAUTI ON : Se ct i o n 68B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o pi e d f r o m r e po r t s a nd s t a t e me nt s f o r s o l i c i t i n g c on t r i b ut i o ns o rf o r a ny c omme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h an s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

SUB- TOTAL

TOTAL ( i f l a s t p a g e o f t h i s s c h e du l e )" D i s c l o s u r e l a w r e q u i r e s c a nd i d a t e c ommi t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f an y r e l a t i v e mak i n g a c o n t r i b u t i o n t o t h ec ommi t t e e . R e l a t i o n s h i p mus t b e s h o w n t o t h e t h i r d d e gr e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s b yma r r i a g e ) I f s u r n a me o f c o n t r i b u t o r i s t h e s ame a s c a nd i d a t e , b u t t h e r e i s n o P a g e o f 4 0f a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r Sc h e d u l e A)

DATE PAC I D NUMBER NAME ANDADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT q I F FORECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE" RECEI VED FUND-( MM/ DD/ YR ) AND PAC CHECK ( i f a p p l i c a b l e ) RA I SENUMBER I NCOMI D# , 1

9-30-o4 L d h i ' f v > 1 c Z~CK#I D# re f t a t s Dc Yo ~ o ' t 9CK# k 6 4 4 &1 6 c o or l C ~I D# . l 'CK#I D#CK#I D#CK#I D#CK#I D#CK#I D#CK#I D#CK#I D#CK#


8/14

T H I S BOX A PP L I E S TO C A ND I D A T E S ' COMMI TTE ES ONLYP u r c h a s e s o f c e r t a i n c a m p a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r m o r e m u s t a l s o b e i n v e n t o r i e d o n S c h e d u l e H ( R e f e r t o S c h e d u l e H i n s t r u c t i o n s . )E x p e n d i t u r e s t o p e r s o n s / e n t i t i e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , m a n a g i n g , o r g a n i z i n g s e r v i c e s m u s t a l s o b e d e t a i l i t e m i z e d o nS c h e d u l e G b y t h e a m o u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e m a d e b y t h e p e r s o n / e n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o m m i t t e e ( R e f e r t oS c h e d u l e G i n s t r u c t i o n s a n d I o w a C o d e 6 8 A . 4 0 2 ( 3 ) ( i ) . )

P a g e

( f o r S c h e d u l e B )

FOR I N S TRUCT I O NS , SEE BACK OF FORM R e s e t . o i r n - SCHEDUL EEXPENDI TURES B MONETARY- - MONEY SPENT FROMCOMMI TTEE ACCOUNT ( R e v . 0 7 / 0 3 ) EXPENDI TURES

STATE PAC COMMI TT EES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR L E GI S L A T I V EC A N DI D A T E S , L I S T T HE CANDI DATE I D E NT I F I C AT I O N NUMBER I N THE DESI GNATED COL UMN AND THE CHECK THI S BOX I FPAC CHECK NUMBER FOR EACH EXPENDI TURE A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA AMENDI NG FORME T H I C S & CAMPAI GN DI SCLOSURE BOARDCOMMI TTEE NAME ( M u s t b e s ame a s o n S t a t e m e n t o f O r g a n i z a t i o n )s o k o C L 6 s ; -~O r - She e t ? I - es e- ; i l oc h A V eCANDI DATE NAME AND ADDRESS TO WHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE( M M / D D/ Y R) AND PACCHECKNUMBER

~D# k er l

S~ i k ~k ~ ~L t r t ~ ` j r1~ 5CK# / 0 0_ 3 6s Vs $ 9y~~~~~~ 5I D # L o r i go k o / ou;4; ? f ' i t l ~ l e P , s i s a

- I - CK# / o a r { ( 6 5 q5 ~f - 1 1r i } A C c b G y ( C = As , ~ I 6 7 d bv tI D # t . C Q I n P u % y t i . 1 . ~ ~ ~ i r '> -00- Oq c K# 100: 5 X ~ ' r ~ / l =~OGI f ) C C ' sq n i r t _ CNof Locus' fSt V t v L~s+~-3)-04 CK# I oo~ , j ( " r 0~ ~0De s 0 0i ~F. S . S03 c

R- 13 - b ` fI D # ~, ~O, 2 C` u s ' t c Sr y e s ` f l - , a r j eCK# I ( ? o - 7 4c ) d c i u e r L i t e w ~r " 44 l 300rOChe r o k ee _ ' T / 0 _: iI D # i L Q r I So , / o L ~ s k t ~ ; b o " CQr Sf d1 - C4 cK#, oo ( o . s g5 7 , l

i l JA ` - o L t . ~I D # C h e r ok e e PC, - 5 1 r 1 a s U: ~ t i ~ k ~ 'CK# / V / C~~ t ? r e k P I I I ~ L ~ t I V I ~f l J - l 7 ` - S l ob.I D # kC ~ I KGA, & Ra cf , a AdsCK# ~0~0 a 2 0 SoLL4A- St A o , x / q l 3 l . 3 uo SUB- TOTAL $ 3 L22 -TOTAL ( i f l a s t p a g e o f t h i s s c h e d u l e ) $


9/14

T HI S BOXAPP L I E S TOCANDI DATES ' COMMI TT EES ONLY :P u r c h a s e s o f c e r t a i n c a mp a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r mo r e m u s t a l s o b e i n v e n t o r i e d o n S c h e d u l e H ( R e f e r t o S c h e d u l e H i n s t r u c t i o n s . )E x p e n d i t u r e s t o p e r s o n s / e n t i t i e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , o r g a n i z i n g s e r v i c e s m u s t a l s o b e d e t a i l i t e m i z e d o nS c h e d u l e G b y t h e a mo u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x p e n d i t u r e made b y t h e p e r s o n / e n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o mmi t t e e . ( R e f e r tS c h e d u l e G i n s t r u c t i o n s a n d I o w a C o d e 6 8 A . 4 0 2 ( 3 ) ( i ) . )

( f o r S c h e d u l e B )

FOR I NSTRUCTI ONS, SEE BACK OF FORM Re s e t Fo r m ` SCHEDULEEXPENDI TURES B MONET ARY- - MONEY SPENT FROM COMMI TT EE ACCOUNT ( R e v 0 7 / 0 3 ) EXPENDI TURE

S TA TE PAC COMMI T TEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR L E G I S L A T I V ECANDI DATES, L I S T THE CANDI DATE I D EN T I F I C AT I O N NUMBER I N T HE DESI GNATED COLUMN AND T HE CHECK T HI S BOX I FPAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROMT HE I OWA AMENDI NG FORME T H I C S & CAMPAI GN DI SCLOSURE BOARD .COMMI TTEE NAME ( Mu s t b e s am e a s o n S t a t e me n t o f O r g a n i z a t i o n )

CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e m e n t ) WAS MADE( MM/ D D/ Y R) AND PACCHECKNUMBERI D # f i So o%wskc ~r 1 7 ~~5 COLO ~OJ G4'

/ 0 - z t i ? 04 CK# / 0 I l i b~ ~ ' T A- ~ e d -1 D #CK#D#CK#D#CK#D#CK#I D#CK#D#CK#I D#CK#

S UB- TOT A L $ a~ ( oSTOTAL ( i f l a s t p a g e o f t h i s s c h e du l e ) $ 3 g 7


10/14

FQR I NSTRUCT I ONS, SEE BACK OF FORMCOMMI TTEE NAME ( Mu s t b e same as o n S t a t e me n t o f O r g a n i z a t i o n )

- 0, weCVnmI ' WeNOTE : De b t s p r e v i o u s l y r e p o r t e d t h a t r e ma i n u n p a i d mu s t b e i n c l u d e d o n t h i sS c h e d u l e , a s w e l l a s an y n e w o b l i g a t i o n s i n c u r r e d i n t h i s p e r i o d

DEBTS/ OBLI GATI ONS REMAI NI NG THI S REPORTI NG PERI OD( DO NOT I NCLUDE LOANS- - SHOWLOANSONSCHEDULE F )

* I f a c t u a l f i g u r e i s u n k n own , s h o w " e s t i m a t e d " b e s i d e t h e f i g u r e .

SCHEDULED I NCURRED( R e v . 0 8 / 9 8 ) 1 I NDEBTEDNESSCHECKTHI S BOXI F AMENDI NGFORM

An " i n c u r r e d d e b t " i s a d e b t f o rg o o d s o r s e r v i c e s o r d e r e d o rr e c e i v e d , b u t n o t p a i d f o r b y t h ee n d o f t h e r e p o r t i n g p e r i o d . ,r e g a r d l e s s o f wh e t h e r an i n v o i ch a s b e e n r e c e i v e d .

Page I I o fa( f o r Sc h e d u l e D)CANDI DATE COMMI TTEES NOTE :* I n c u r r e d i n d e b t e d n e s s a l s o i n c l u d e s e a c h p e r s o n / e n t i t y w i t h wh om t h e c a n d i d a t e ' s c o mm i t t e e h a s e n t e r e d i n t o a c o n t r a c t d u r i n g t h e r e p o r t i n g p e r i o d f o r f u t u r eo r c o n t i n u i n g p e r f o r m a n c e . E n t e r t h e name o f t h e c o n s u l t a n t wh o p r o v i d e s o r p r o c u r e s s e r v i c e s f o r i t e m s s u c h a s a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , oo r g a n i z i n g s e r v i c e s . R e p o r t o n S c h e d u l e G t h e n a t u r e o f p e r f o r m a n c e a n d t h e e s t i m a t e d p e r f o r m a n c e r e a s o n a b l y e x p e c t e d o f t h e c o n s u l t a n t .

DATE DESCRI PT I ON OFGOODS OR BALANCE OWED ATI NCURRED NAME ANDADDRESS OF PERSON SERVI CES PROVI DED OR CLOSE OF( MM/ DD/ YR) TOWHOM DEBT OR OBL I GAT I ON I S OWED PURCHASED REPORTI NGPERI OD*t o n - s o k o j o t o Sk f ' 1 ~r

$Di - l 1 1 1 r r i ~6s y e i _ _~~ ; n c ~ r c r S c c - S

- I- dS - C 1 ` ~ 1 t t r

l . _ CWJC ' i f -1 3 o b ~ r l1 - ~ St . - ~ ` t i n o f r q l F s e r( a I l ~ r U ~c kemkee , ~. ~ _~ t o l ~ 7 3L o r i s o k o l o Lo SkY 7 - 3 c r - n ' 4 65Y5 1 ` &e SPA l o o.41s4et " A l - 5 1 0 - ' - ) ~. _ 0- dl .

__ ()q- r ~z 4~t r ~ dyes o t : ~ ~ ~ s , ~ p ~ j , 1i q 6 C I SAp q per d

3ci s 41- oamd ey . ,

SUB- TOTAL $5f,58TOTAL DEBTS OWED BY COMMI TTEE AT THE END OF T HI S REPORTI NGPERI OD $


11/14

FOR I N STRUCT I ONS, SEEBACK OF FORMCOMMI TTEE NAME ( Mu s t b e same a s o n S t a t e me n t o f O r g a n i z a t i o n )_S 0 k o / o , JS' . 4 ~ I ~ S h e ~e~ t f Sf ~R ~~ , J L CC ` i -A . - Y l f rNOTE : De b t s p r e v i o u s l y r e p o r t e d t h a t r e ma i n u n p a i d must b e i n c l u d e d o n t h i sS c h e d u l e , a s w e l l a s a n y n e w o b l i g a t i o n s i n c u r r e d i n t h i s p e r i o d

DEBTSI OBLI GAT I ONS REMAI NI NG THI S REPORTI NG PERI OD( DONOT I NCLUDE LOANS- - SHOWLOANSONSCHEDULE F)

* I f a c t u a l f i g u r e i s u n k n o w n , s h o w " e s t i m a t e d " b e s i d e t h e f i g u r e

SCHEDULED I NCURRED( R e v . 0 8 / 9 8 ) 1 I NDEBTEDNESCHECKTHI S BOXI F AMENDI NGFORM

An " i n c u r r e d d e b t " i s a d e b t f o rg o o d s o r s e r v i c e s o r d e r e d o rr e c e i v e d , b u t n o t p a i d f o r b y t he n d o f t h e r e p o r t i n g p e r i o d . ,r e g a r d l e s s o f wh e t h e r a n i n v o ih a s b e e n r e c e i v e d .

Pa g e o f( f o r S c he d u l e D )

CANDI DATE COMMI TTEES NOTE :* I n c u r r e d i n d e b t e d n e s s a l s o i n c l u d e s e a c h p e r s o n / e n t i t y w i t h wh om t h e c a n d i d a t e ' s c o mm i t t e e h a s e n t e r e d i n t o a c o n t r a c t d u r i n g t h e r e p o r t i n g p e r i o d f o r f u t u r eo r c o n t i n u i n g p e r f o r m a n c e . E n t e r t h e name o f t h e c o n s u l t a n t wh o p r o v i d e s o r p r o c u r e s s e r v i c e s f o r i t e m s s u c h a s a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g ,o r g a n i z i n g s e r v i c e s . R e p o r t o n S c h e d u l e G t h e n a t u r e o f p e r f o r m a n c e a n d t h e e s t i m a t e d p e r f o r m a n c e r e a s o n a b l y e x p e c t e d o f t h e c o n s u l t a n t .

DATEI NCURRED( MM/ DD/ YR ) NAME ANDADDRESS OF PERSONT O WHOM DEBT OR OBL I GA T I O N I S OWED

DES C RI P T I ON OF GOODS ORSERVI CES PROVI DED ORPURCHASEDBALANCEOWED ATCLOSE OF

REPORTI NGPER I OD*4 o n Sokal awsk'` T f i , , le

~ x q ' ~ q g t r d s t y n s $

i + r t f n e ~a C~ I

~d _ Oa ? - 6 ` ~

- 7 - 0+ r( ~ t~I QS ,-f ( ' C - - ~ g 5 ~ e p i r r s

r n P` z 1 . 5

mPaf s 3 0 , o a

- I t ~ ~~ mP~; ~s - 5- 5-S UB- T O T AL $

q9 1 , LTOTAL DEBTS OWED BY COMMI TTEE AT T HE END OF T HI S REPORTI NGPER I OD $


12/14

FOR I NSTRUCT I ONS, SEE BACK OF FORMCOMMI TTEE NAME ( M u s t b e same a s o n St a t eme n t o f O r g a n i z a t i o n )

NOTE : De b t s p r e v i o u s l y r e p o r t e d t h a t r e ma i n u n p a i d must b e i n c l u d e d o n t h i sS c h e d u l e , a s w e l l a s a ny n e w o b l i g a t i o n s i n c u r r e d i n t h i s p e r i o d .

DEBTS/ OBL I GAT I ONS REMA I NI NG T HI S REPORTI NG PERI OD( DO NOT I NCLUDE LOANS - - SHOWLOANS ON SCHEDULE F )

" I f a c t u a l f i g u r e i s u n k n o w n , s h o w " e s t i ma t e d " b e s i d e t h e f i g u r e .

Rese t F or m

SCHEDULED I NCURRED( R e v . 0 8 / 9 8 ) 1 I NDEBTEDNESCHECK T HI S BOXI F AMENDI NGFORM

An " i n c u r r e d d e b t " i s a d e b t f o rg o o d s o r s e r v i c e s o r d e r e d o rr e c e i v e d , b u t n o t p a i d f o r b y t h ee n d o f t h e r e p o r t i n g p e r i o d . ,r e g a r d l e s s o f wh e t h e r a n i n v o i ch a s b e e n r e c e i v e d .

Page -3 o fa( f o r Sc h e d u l e D )CANDI DATE COMMI TTEES NOTE :' I n c u r r e d i n d e b t e d n e s s a l s o i n c l u d e s e a c h p e r s o n / e n t i t y w i t h wh om t h e c a n d i d a t e ' s c o mm i t t e e h a s e n t e r e d i n t o a c o n t r a c t d u r i n g t h e r e p o r t i n g p e r i o d f o r f u t u r eo r c o n t i n u i n g p e r f o r m a n c e . E n t e r t h e name o f t h e c o n s u l t a n t Wh o p r o v i d e s o r p r o c u r e s s e r v i c e s f o r i t e m s s u c h a s a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , oo r g a n i z i n g s e r v i c e s . R e p o r t o n S c h e d u l e G t h e n a t u r e o f p e r f o r m a n c e a n d t h e e s t i ma t e d p e r f o r ma n c e r e a s o n a b l y e x p e c t e d o f t h e c o n s u l t a n t .

DATEI NCURRED( MM/ DD / YR) NAME AND ADDRESS OF PERSONTOWHOM DEBT OR OBL I GAT I ON I S OWED

DESCRI PT I ON OF GOODS ORSERVI CES PROVI DED ORPURCHASED

BALANCE OWED ATCLOSE OFREPORTI NGPERI OD"

S L o r , Sa k o 1 a 1 - ) SLl S - ~ v t . SP 5 / 0 ' - - ) 5 mI l r i j t 3756 . ~ 1 - 7 e n ; f e r n I ' I e - a33l b3 ~

SUB- TOTAL $, r , ) , 33 i , 3~

TOTAL DEBTS OWED BY COMMI TTEE AT T HE END OF T HI S REPORTI NG PERI OD $34a i , s i


13/14

FOR I NSTRUCTI ONS, SEEBACK OFFORMCOMMI TTEENAME ( Mu s t b e s ame a s o n St a t e me nt o f Or g ani z a t i on)SoKca a cpsk

SUB- TOTAL

TOTAL ( i f l a s tp a g e o f t h i ss c h e du l e )

SCHEDULEE I N KI ND

( Re v . 0 6 / 9 7 ) 1 CONTRI BUTI ONS

r l CHECKTHI S BOXI FAMENDINGFORM

* D i s c l o s ur e l a w r e q u i r e s c a nd i d at e s t o d i s c l os e t he r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a n i n k i n d c o n t r i b u t i o n t o t hec o mmi t t e e . Rel a t i ons hi p mus t be shown t o t he t h i r d d eg r e e o f c ons a ng u i n i t y ( b l o od r e l a t i v e s ) a nd a f f i n i t y ( r e l a t i v e s ( f o r S c h ed u l e E)by ma r r i a g e) . ( S ee P a g e 2 o f f o r ms p a c k e t . ) I f sur name o f c o n t r i b u t o r i s t he sa me a s c a nd i d a t e , bu t t her e i s nof a m i l i a l r e l a t i o n s h i p , e nt e r " n o t a pp l i c a bl e " i n t he r e l a t i o n s h i p c o l u mn .

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