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03/12/2010 16:41 FAX 6413243682 WoRTH COUNTY FOR INSTRUCTIONS, SEE BACK OF FORM (CHECK ONE: eruits BEY, (Thisisan inital Statement of Orgarizaon BR ETHES CSURE E This ic an amended” statement of Organizaton\:° + Ao tia Sommart of Crgateten shoul be fed wt 10 dye 3:51 centbulors, malig exponctave aroun mesbocrose Vanden ct be ed | COT ‘un 50 doe ofa change. Ponaes nay be inposed kr iateiedStatumarts Sf ooanendar ———— a [CORTE WAME (Required by aw) MORTH COUNTY REPUBLICAN CENTRAL COMMITTEE tiPORTANT: incite type ot commntie you are raperting for: (+ Statewie/agittive Candidate (2 )ettewide PAC (3 Jane Party (4 )Counny/Local Candidate (§ )County PAC ( § Wallet eruerranchice [Commie (7 Couny/Oity Centre! Commitee (8 )Support sate of condideies st cundKsies under purpooe of eonmatiee) COMMITTEE TREASURER (This ackress voed for al ruminders COMMITTEE CHAIR (List acftona offcers on separate pape) (Requted by aw) od coresporence) Tare JEFFREY CORBALL ating Address 1377 430TH STREET iy, Ste — Zip Code NORTHWOOD TA 50459 Tiating Aare Gy Sam Tip Cote Home Phone( Home Prone (641 324-1136 ay Prone ( DeyPrene; CHL _ 641-529-0975 PAGS: INDICATE PURPOSE OF COMMITTEE A candisien ar orice Soup Dai: Poti! Party Of apaabi) ‘Your Stang fr Econ: Eero Can FT ET Ca ES Date of eto: ei San am EAs yp eg Ae Face Rar ot nari aT yp oR aig na ang RS oy 7 Eo Say Sate Tie Herne Phone ( ni Prove Im Taw ran coneinas, capo pales DISPOSITION OF BALANCE OF FUNDS UPON DISSOLUTION (terete mgansy wr ve Soma, a an onan ec np FP en mh cen me ea ear hen wm nd ler nacannce Bape oan spe candle eon rho non Tan Boe ere tie ors wat © arate {ing snare isa naan Oe sage be see nee eet neus Bu oes epee PAG Gmarae e [Sete ocorts od ety plone pre. Fly, | fr a somes Gare Rev Been INOONCE Och eoeahOne om) CDI. 3-10-2010 a ‘Signature of Gandia or Gharperson (fa PAG) “Bats lanes

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