05/28/03 WED 12:19 FAX 319 398 5228 .R. CHAMBER Foam DR-OTC ‘ONE-TIME CONTRIBUTION IN EXCESS OF $750.8 A ICS AND CAMPAIGN DISCLOSURE BOARD 514 EAST LOCUST, SUITE 104 DES MOINES, IA 50309-1912 Fax: (515)261-3701 PERMANENT ORGANIZATION wor lowa.goviathies Per oneers ONTRIBUTION IN EXCESS OF $750 Pose = ERMANENT ORGANIZATION Checked Computer ae lowa Code section 56,6(6) requis a permanent arganization that cantrbutes in excess of $750 to register and fle reports @s @ PAC. This formis Intended to serve those purposes. The form ‘must be filed withthe Board on or before the tenth day ofthe cate the check was iss ORGANIZATION MAKING CONTRIBUTIO? ‘Merey Medical Center NOS 01 14 Steet SE Cedar Rapids, Iowa $2403, ating Adress Ty, Sate, Zp Code 3193986133, ‘rea Code & Telephone No Erna Aderoas_(Optonaly CONTACT PERSON FOR THE ORGANIZATION: Sin Tinker ETS ou suet SE Cedar Rapids, Iowa $2403, inaing adress ‘iy, Sa. Zip 3193586133, Enal ress (Optonal ‘Asa Code & Teeshore Number (COMMITTEE RECEIVING THE CONTRIBUTION: Vote Yes Commitee Ll 3,000.00 Rare of Commie ae of Conon Rerourt 424 First Avenue NE. Cedar Rapids, Iowa 52401 6-10-03 Linn sing Adcross iy Sat, Zip Code Baie oreieevon aur Aa) reorbetcedarapids.org 319.398.5317, Tie-kind Combat. Deserbe Ema Aacress (Favalano) “Fiea Code & Terohone Number ‘Ctra to use ts orm (One campaign contbuton in excess of $750 was made toa slate or local cancidate, party, polticl commits (PAC) for ether a ccaeldato ora balot sue, ot ary ther organization at advocalos he elacon or defeat fa candidat or balot issue ‘Must bea permanent organization not established for election purposes. fo person gave money fo the organtzaton forthe purpose of tne ergrization thon ung the money to make the contbuton, Ie contrbuton was made to @ candidate, no funds ror a corporation or ether prohbted contributor under lowa Code section $6.15 \wora used i maka the contuiio (is coos not apa oa contrbuson rads toa balt issue commits) ‘Only one cont-butn fo any campalgn commitee except era Balt issue earmites was made ma calendar year. Nomore than one ‘contbuton may ba made © any one ballet ssue commitee during a bala Issue eiecien. ore than one contribution and re tla | ‘amount of he contoutonsexcoeds 8750, tne orgarization must regster win the Board asa plea committe (PAC) winin 10 days of ‘ossing the $750 teshol affirm thatthe contribution reported above is accurate. | futher aff thatthe information concerning True to the best of my knowledge. | understand that by fling this form. | am subject to the laws found in tive ries found in chapter 361. | algo Understand that the failure fo timely file this form leads to Oe nite tania alr to fete orn ay lead to adionl ck and eminal sanctions e (21 Hes Date ' “Contribution” includes goods or services that are provided for free or otherwise less than fair market value.