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t0,ETHICS Al{t) "

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JUL13 AH9: 12.
m09 Comm. #

w lndexed
.Audlted

FOR INSTRUGTIONS
SEE BACK OF FORM
flt am filing this form to use the shorter'paidfor bt' attribution.The committeewill not be crossingthe $750 threshold.' This form must be
filet priorto the distibution or postingof the politicalmaterial.
'lf the ammifree crosses fie fltre shald,a DR-1 Statementof Organiation
must be frledwithin 10 days of the commifree's accepttngcot tibufnns, making
expandftures,or incuning lndebtednessexeedlng $7ffi. ln addiilon, the commiflee will be requiredto file campaign dr'sclosurereporfs.

COMMIITEE NAME J-J 6 ca4CiOate's mustiryIudepe candidate's

committee lastnamein thenameof thecommitee).

IMPORTANT: lndl@te typo of commltbe you are reglsterlng for:

t )Statwlde/Leglslatlve/Judge SEndlng for Retendon Gandldate-(2JStatevtHe PAC ( 3 )State Party { 4 )county GantrialGommlttee
!]Cgunty Crndldato _(6 )Clty Candldato ( 7 )School Board or Other Polltlcal Subdlvlslon Candldate ( I )County PAC ( I )CIty pAC
Board or Other Poltfical SuMlvlslon PAC ( 11 ) Local Ballot lssue (lncludlns commltiee Involved ln

COfiIMITTEE CHAR (mandatory for all commlttees ercept a CANDIDATE (mandatory except for a non-candldate commfttoe)
candldate's

City, State I J Ap Code J J

- Check One Box El Advocatebr/agatnstcar$idate(s)

County/Local Gandldates dnd All Other Commtttees Enten

county: PnlJ<
(lf adlve In multiple ballot issue elecflons, attrachlist of countes or enter
"statewide")

q-g- 0q
DateorEfecnon,

STATEMENTOF AFFIRMATION:By flllng thls document thE commlttso affirms the followlng:

1. The commitee and all persorn connad with the commttbeunderstandthat they are subJectto the larenin lowa CodechapteF 68Aand 688 andthe edmlnisiratirre
rulesIn Chapter351of the louraAdmlnisfatve Codo.
2. ThatlowaCodesecdon6SA.405andrules3til--4.3Sthrough4.43requiIgtheplacementofthewords"paidforbf
andthenameofthecommiteoonalpolitcal
mabrials exceptforthos€ ibms exempt€dby stdrto or rule.
3. That lovvaCodes€{fion 68A.503and rules351{.214 through4.52 prohibit the receiptof corporab contributlonsby all commltteeso@eptfor statevylde
and local
ballotissuePACs.
4., Thatif the conrnitteeexceeds$750 ln empahn actvlty, aDR-1 Statementof Organizdionmustbo ffledwithln 10 dq,s and the commifieeis requiredto file campaign
dlscl6rB reports.
5. Th3tthls form ls flled priorb the disfibuuonor posing of poliuial materialrequlrlngthe "paldbr blf attibuflon.

t /ts lq Dats sbnsd