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HICS AND CAMPAIGN DISCLOSURE BOARD Form

510 EAST 12th, SUITE 1A VERIFIED STATEMENT
REGISTRATION
DES MOINES, IA 50319 (Out-of-State Committees)
www.lowa.govltethics (Rev. 07/03)
D STATEMENT REGISTRATION For offircgyse only
(Out-of-State Committee) Comm, #
Indexed _____
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DJJPLICATE .
SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND Audited
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION . Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON SACK OF FORM .
THIS FORM MUST , BE FIL ED FOR EACH CONT RIBUTIO N IN EXCES S-of $so Computer ___------_________

COMMITTEE NAME
Offlclal Name of Out-of-State Committee (Do not abbreviate committee name . Written explanation must be provided for Acronym) .

STATE OR FEDERAL JURISDICTION WHERE COMMITTEE PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
IS REGISTERED OR OPERATES (Use separate page If needed to list more than one entity)
me of Jurisdiction

n Address
.~
C"fty' St~ t~8, ZI CoIq Talep n City, State, Zip Code
W~fTJtl11~. .

PURPOSE OF COMMITTEE

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident `Jams of r , %mmittae

Ma Ilng Address Mauin Addr6$9 LI~-~(itJ

q,-Vj- .St=
Date If In-Kind Contribution, Describe

I attest that the contribution reported above Is accurate end that the information about this out-of-state
committee Is correct and accurate to the best of my knowledge. I also attest that the reports tiled In the named jurisdiction comply with requirements that are
substantially simlier to Iowa Code section 68A.6, Including the disclosure of all contributions moalved and all expendliurea rhmds, I further attest that the
nlrlbution reported above Was made from an account that does not accept contributions from cwporallons or other prohibited contributors under Iowa Code
n 88A.15, unless the e recipient committee is a ballot issue committee. I understand that potential civil and criminal penalties may apply unless a copy of
rm has been filed th he Iowa Ethics and Campaign Dlsolosung tjoard within 15 days of the date of the contribution .

(Person submitting form) (Title) (Date