001/001

PETER ;pti CCtjTP,o ;TrrR

11' ^ nfl ; 1611 FAX 3193452991
FAX N0, 319+233+1810 P, 02/03
FEB-11-2005 FRI 03 :19 PH FIRST SECURITY ST. BANK
Fonn DR-OTC
V IA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12T" , SUITE 1A ONE-TIME CONTRIBUTION IN
DES MOINES, IA 50319 FXCESS OF S750 6T A
PERMANENT ORGANIZATION
Fox; (515)281-3701
www .IdMra .govlethics Poro4ft~M only

4E CONTRIBUTION IN
Indexed
~- 2~"ONE-TI' EXCESS OF $750 Audited
' y IfaA PERMANENT ORGANIZATION Checked
Computer
Iq,.wa(j:iiiBe section
SSA .d02(9) requires a permanent organization that contribulea In excess of
# 60 to register and rile reports as o PAC . This form IS Intended to serve those purposes, The

4ao L
iQL~1 mUSj a_fled with the Poerd on or before the_ tenth day or !he date the check was issued.
ORGANIZATION MAKING CONTRIBUTION :'

Peterson Co ntractor s Inc-

Name -
Reinbeck IA 50669
Mailing /ufCress City, Stato, Zip Code
319-345-2713
Email Address (Optional) Area Code & Telephone No .

CONTACT PERSON FOR THE ORGANIZATION :

Cordcll. Peterson
Name
PO Box A Reinbeck 111 50669
Mailing Address Cay, State, Zip
- ____33.445.-. 7 713
Email Address (Oplinnal) Area C ode & Te lephone N umber

CANDIDATE OR COMMITTEE RECEIVING THE CONTRIBUTION :

Mkaro Coalition for Better Streets
Name of Cantild~to or Cormlitlee
P.O. Dox 1001 Watrsioo, Iowa 30704

11 .ti4ng hddre :cs City, State, Zip Code -.

31923 5-0050

Em ail AddreL* (if available) Arse Code & Telepl+onn Number

If 2ntribuiion to canddatc, disclose source or orlgirwl funds used to make

such wnL ibuaon (MuAcfl additional pages if noce&swy) . If In-Kind Contribution, Describe

Critaria to use flti8 foal :

t- One campaign aadn'bution in excess of $760 was Made to a AM is or bcil candIdale, party, political rnrnmatee (PAC) for eiU rer a
candidate or a ballot isxre, or any ott+tr ong an"Gon 1tial advocates the doUiw or dcfoat of a candidate or baloi Lssuo .
2. Mrrct bo a permanent or~)anvadon not established for eledloan purposes .
9- No perzzon pave money to the organizJrtk)n for the purpose of ft organization then using the money to make the conbibulion.
4. If 111e contribution v-s muck to a oardldalc, no fund:- horn a oorporaliorn or other pmhbhod contributor under Iowa Code sac0on
W .S03 wore used to make the contribution (this does not apply to a contribution made to a bcrlbl Issue committee) .
5. Only one crrtbution b any campaign committee cxmpf for a ballot issue committee was made In a cNendar year. No more than ono
annlribution maybe mado to anyone bolkrl VAuc commidee durlnp a ballot issue efectar. If more then one oontribubon and the total
amount of the contributions exceed 5750, the organization must reylater rith the Board as apolitical cxnmillee (PAC) within 10 days of
orossirq the $750 threshold .

Statement of Affirmation :

,contribution sported above Is aoolrate . I krrMur affirm that the Intomution conneming the oryontlalion s
dcrstsnd 0141 by ping thb lams 1 am subied b lho Lows found in fo .ru CO& chapter 6M and
that t (:,11X0 to tbneiy Nc U rk torn loads to die inpocilion of Ovil renetbm and the
civil and criminal sanctions .

~-IJ°05
Date

nA.we ,Mar 4Wrn .i.lorl rnr 0

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