Sep 1_'t3 05 09 :00p GORDON a ROBERTA KOKENGE 712-542-4054 p .

FOR INSTRUCTIONS, SEE BACK OF FORM

P,aq&
CHECK ONE: Reset Form FORM STATEMENT
0 This is an initial" Statement of Organization DR-1 of
U This is an amended' Statement of Organization '~"1` (REV. 052005) ORGANIZATION
An initial Statement of Organization must be fled within 10 days of the committee's accepting contributions, For Office Use Only
making expenditures, or incurring indebtedness exceeding $750 . Amendments must be filed within 30 days of Comm .
a change. Penalties may be imposedforfate-Fled Statements of Organization . A candidate with an open Indexed
committee that exceeds $750 in activity for anotherofe ~sft file within 10 days either anew or amended Audited
DR-1 disclosing information concerning the campaign flortfie new office sought. Computer

COMMITTEE NAME 1 1

IMPORTANT: Indicate type of committee you are reporting for.

( 1 )Statewide/LegislativelJudge Standing for Retention Candidate ( 2 )Statewide PAC ( 3 )State Party ( 4 )County Central Committee
( 5 )County Candidate (6 )City Candidate (7 )School Board or Other Political Subdivision Candidate (8 )County PAC (S )City PAC
( 10 )School Board or Other Political Subdivision PAC (11 )Local Ballot Issue
COMMITTEE TREASURER (mandatory for all committees) COMMITTEE CHAIR (mandatory except fora candidate's committee)
Name 1 1 Name 1 1 A/`
~c ~c? 41
Mailing Address .L b Mailing Address 1 1

City, ~,;tale 1 Zip Code 11 City, Slate 11 Zip Code 1 1

Phone (7/;2) Sy~ '~'eLS7Y Phone ( )

e-Mail vh-dIi'twir "-~

I'° ~ '
INDICATE PURPOSE OF C MMITTEE - Check One Box
Comment or description:
All Candidates Enter.
Office Sought:

Political Party (if applicable) ,V 4 Year Standing for Election . 4Z;2C1C).5~

County/Local Candidates ant( Local BallottFranchise Committees Enter.
Date of Election :

Bank Account Name 1 1 Candidate name 3 Address or Parent Entity IPACs. if applicable).

AL 1 1 Affiliate or Sp onsor

Name of Financial Institutio e of Account 1 1 Mailing Address 1 1

Mailing Address 1 1 City 1 1 State 1 1 Zip

City 1 State 1 1 Zip 1

- y0; 5"
1 l
Phone C7/
:L) y` _Vv
't
Mail

STATEMENT OF AFFIRMATION: By filing this document the committee affirms the following :

1. The committee and all persons connected with the committee understand that they are subject to the laws in Iowa Code chapters 58A and 68B and the administrative
rules in Chapter 351 of the Iowa Administrative Code.
2. That Iowa Code section 6aA.402 and rule 351--4 .9 require thefiling of disclosure reports and that the failureto file these reports on or befere the required duedates
subjects the candidate or chairperson (in the case of committees otherthan a candidate's committee) to the automatic assessment of a civil penalty and the possible
imposition of other criminal and civil sanctions.
3. That Iowa Code section 68A.405 and rules 351-4.38 through 4.43 require the placement of the words 'paid for by' and the name of the committee on all political
materials except for those items exempted by statute or rule. A committee filing this statement for purposes of using the shorter 'paid for by' and who have not crossed
the $750 shall notify the Boon! that the $750 threshold will not be crossed.
4. That Iowa Code section 68A 503 and rules 351-4.44 through 4 .52 prohibit the receipt of corporate contributions by all committees except for statewide and local ballot
issue PACs.
5. A candidate and a candidate's committee may only expend campaign funds as permitted by law& code sections 68A.301 through 58A.303 and rule 351--4 .25.
ee will continue to file oisdosure reports until all activity has ceased, committee funds spent, debtsresolved, and a final report and a statement of
as be

00, 9 e Signed
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chreof Cenddete. OR, for all otherb-
mmttees, Cha
-irperfo n ete Signed