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FOR INSTRUCTIONS, SEE BACK d FORM

t' . D R-S FA Statement pf
r._. I am filing this form to use the shorter "paid for attribution . T~ e Corn itteeVill rint be (Rev . 01/2006) Organization
rrosslnq the 5750 threshold .' "PalC For By"

For
NEW
.a n inihalDR-1
committee crosses the threshold t of Organization muss be t led within 10 days pfftce Use my
r fthe commilYee's occep8ng contributions" making ex excnoding "5750. In Comm . #
addition, the committee will be required to file campaign B Indexed
Audited
Compu ter
-'L, i, -, ^ o_ L L -krc'l .~ t.( .frP
lr
COMMITTEE NAME r. T (A candidate's committPe must include the candidate's last name In the name of the committee.)

IMPORTANT: Indicate type o corn tree you are registering for: 5

( 1 )StntewidelLegislativelJudge Standing for Retention Candidate ( 2 )Statewide PAC (3 )State Party (4 )County Central Committee
( S )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Polltlcal Subdivision Candidate (8 )County PAC ( 9 )City PAC
~ 10 )School Board or Other Polltlcai Subdivision PAC ( 11 ) Local Ballot Issue(including committee involved in multip le cltylcounty ballot issues)

COMMITTEE TREASURER (mandatory for all committees) CANDIDATE/ COMMITTEE CHAIR (mandatory except for a candidate's
committee)
N.-ime Name
I rQ ~ t/ .
` ~~~ ! Sly
~ I
t~la, inq Address r. Mailinq AddreSS w r. ~ ~
SS S- U~, ~_Jrna
Ch, State -
), Cr_y C,-) -7 A S Z~~ yj
Zip Code n r

e-mail

INDICATE PURPOSE OF COMMITTEE - Check One Box Advocate forlagainst candldate(s) 0 Advocate for ballet issue(s)
Comment or description : Advocate against ballot issues)

All Candidates Ent County/Local Candidates and Local Ballot Committees Enter :
Office Sought' y~S c, ~' C U .S t~l Y~ ,
County : S S _
Pnlltlcal Pal 0 applicable) t? Ip (If active in muff pie ballot Issue elections . attach list of counhes

D ;trill Dote of Election : I I - -I - D ~,

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

! . The committee and sll pemcnc cannected with the committee undertand that they are subject to the I9ws in Iowa Code chapter: 68A and 66E snd the edmin~srr:rt~~ " e
rtif n^, it Chanter °S 1 of the lows Admirinfrail " re Code
? That Icw.r ; Code Section 68.A 405 and rules _'_?-4 38 through 4 43 require the placement of the words 'paid for by' and the name of the cr;mrnlttCe on sll oelitl -.a
r1 .it"ial" except rc . theee ~tems exempted et' statute or rijie .

3 . Thai icwa Code section 68A.503 and ruins ,51 --d AA through d 52 prohlbitthe reeelpt of corporate contributions by all committees except !or statewide and a:~i bale-"
issue PAC',
4. That if the committee exceed ; 5750 ~n camo .3igr activity . a DR "t Stslement of Organization must be filed within 10 days and the cernmlitee is required to t,le c3 no .3,^n
dr-,aosurr escort.^, .

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