UFCW431 FAX NO, 5633238763 P.

01
OCT-19-04 TUE 11 02 AM

FOR INSTRUCPONS, SE RACK OF FORM FORM

.F DR-2 olscLOSUR~
(REV . 02196) REPORT
~.)1SG1~~)SURE SUMMARY PAGE
ForOffce Use nl ~ /
Comm. #
CC)MMITTV=~: NAMf. (Ilr1tIJ( I)C sarrle as on Staternent of Organization)
District Union 431, LJFC, ;W, Political Ac't_ion Ac count Indexed
Audited
IMPQIi1'ANT: IstdjC .jt,: typ+ . of committee you are reporting f or : Computer
( t )8latowlde/Legislative Candidate (2 )51alewide PAC (3 )State Party (b )County/Local Candidate
( 5 )County PAC.; ( G )BAllo1 lasucll=ranchice Committee ( 7 )County/City Central Committee
(il Elms
_)Suport of Calutidale +- ,_.r. _.,
10/19/04

~~ F TREASUC~ER`{- a tVp~crsonfiling
SIGNATUBE thisreport) TELEPHONE DATE SIGNED

17c~nalties Due For Late Filed Reports Range from $10 to $400

51 E lN5T~tLICTIt~NS ON SACK AND COMPLETE 7,y~ FS~?l,L ;

/A (1) ELECTION I(2)~ON-ELECTION YEAR .
(r.:port date) I Indicate one

i
ncFir cK it AhnrNr?a~ne°N~r °ro Fii'r~or~r DATED t. Local Cornmitt¢es, entor Date of Election

County & local Commltiees, enter County in

[] Ghoc:k if ll -ris i^" f}n~~l (termination) report and attac" cc of Dissolution Form DR-3 . which Election h held
(You n- rctst cnntirlt~i, to file feports until a Notice of Dissolution is filed .)

STATEMENT OF CASM ON HAND

CASN OIJ 1-IANf7 rtt IItE beginrtirttl of tire reporting period . (this is the Lotal
of all tYlUriiB" Jmsld v y the committee . This amount MUST be the
~.~an~t~:; a :, thr: c:arsh on ftand al the and of tha last reporting period, 8900 .00
or must lao zc;ro if this; i~~ fir, t report filed .) . . . . . . . . _ ._ . . . . . . . . . . ._ . . . . . . . . . . ._____ . . . . ._ . . . . . .__ . ._ . . . . . . . . . . . . . . . . .$

AI)C''fC)~1"AL. f4°iC3NCY TAi~>=N IN THIS PERIOD 1 600 .00

Scitr:ctlrla A : C:r~ h Contrik~tations total (Attach Schedule A) . . . . ._ . . . . . . . .---_ ._____ ._ . ._________ .___-___ .__ .

Scftr;cFulo G : F= anal-r~i .ing lrvcnts total (Attach Schedule C) .- . . . . ._, . . . ._ . . . ._ .__ . . . . . . . ._ . . . . . . . ., . . ., . . . .

SrhndUlv: h : I,.aans f~ieceive:d tat:~l (Attach Schedule F)_ ._ . . . . ._ ._ . . . ._. . . . . . . . . . . ., . ., . . . . . . . . ., . ., . . . . . . . . . .

Sc ;hcdulo hl : Tot.vl S;sl~s of Campaign Property (Attach Schedule H) .. .., .. ..... ...., ......, . ....... .

_ ~ilecflal o kl ap plias to Candidat+?s' Committees Onl r

10500 .00
SU f3-TOTAL ,.... $
Sl1f3TRl1C :T l'1;}1'Ah. MC)NE'Y SPENT THIS PERIOD 500 .00
Sc}t~:ch.rle L~ : E"xnc~i~ditures total (Attach Schedule f3) . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .- . .-_ ._-- . . . . . .
Sche~cl:rh; }"~ : l. .o ;~n (tc:payments total (Attach Schedule F) ______ . . . . . . . . . . ._ . . .____ . . . . . . . . . .__ . . . . . . . . . . ., .,

(;ASH C)N I1AND al thr, end of this reporting period (if final report, balance must 10000 .00

UNPAIC~ fflL,l..S (Frc~rrt :ycltedllle t1 _ Attach Schedule D) . . . . . . . . . . ., . . . . . . . . . . . . .- . . . . . . . .__ . .___ . . . . . ._ . . . . .______ . ._ . ._ .$

IN KIND CONTR113UTIC4~S (i -°rom Schedulea E - Attach Schedule E) .___ ._ ._ . ._ . . .._ .____ . .__ . . . . ._ .___ .____ . . . . ._ . . .$
OUTSTANDING LOAN :"., (Frorri Schedule F - Attach Schedule F) .__.__.. .. . .. ......... .._ .. ....__._ ._ .... ., .. .. . .. .. .$
CANDIDATE CUMMf"f1"EE: ONLY :
YES NO
CONSUI.YAN'f' fcRE:AKf30WN (Schedule G Attached?)
VAI..UE Of' CAMPAIGN Pt~ROF°f;?RTY (From Schedule FI - Attach Schedule H)
 OCT-19-04 TUE 11 ;02 AM UFCW431 FAX N0, 5633238763 P. 02

For Instructions, See Back of Form SCHEDULE

A I MONETARY
CONTRIBUTIONS -- MONEY TAKEN IN (Rev . 02/96) I RECEIPTS
(Inciuding candidate's personal funds)
CHECK THIS BOX IF
COMMITTEE NAME! (mist t)e sanle as on Statement of Organization) AMENDING FORM
District Union 4, 31, UFCW, Political Action Account

STATE CANUIUAfI:.r+ NGTh : If A CC7NfI+IL1UfION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND'rl Ill. PAC
;CHECK NUMNF_R IN THE pESIGNATEO COLIIMN- A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
pISCLOSLIRI. GOARU.

CAUTION ; Section BOL3 ."s2A(r), Iowa Code, prohibits the use of Information copied from reports and statements for soliciting contributions or
for any cornrrmrci,al Isurnose by Any parson other than statutory political committees .

DATE r'AO Ih NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

RECEIVED (if applicable) TO CANDIDATE' RECEIVED
(MMIDDIYrt) AND PAC CHECK (if applicable)
NUMBER

0£3/31 /()' W# UFCW District Local 431 Transmittal Acc $ 1600 .00
CKft

IDY

C K11

CIQr1

CKff

CI`1F

r._
-__ -
Ileft -_

CIG1

Clot

CK#

CI<J1

CI :'1t

SUB-TOTAL
$
TOTAL (if last page of this schedule) 1600 .00
` L11sr1osure I11W r°01111113 cUodiJalr,: cornrrrillces to di::cloao the relationship of any relative making ai contribution to the
cornrniucc, W-talions;flip rrrucl Lc shown to the third degree of consanguinity (blood relatives) and affinity (relatives by 1 1
martlape) (;tee Piiy-s 2 of forms packet.) . If surname of contributor 1s the same as candidate, but there is no page of _
familial mlatianshill, e:ntr:r "not applicable" in the relationship column . (for Schedule A)
 OCT-19-04 TUE 11 :03 AM UFCW431 FAX NO . 5633238763 P, 03

FOR INSTRUCTIONS, SCE BACK OF FORV SCHEDULE

E3 MONETARY
EXPENDITURE:) -- MONEY SPENT FROM COMMITTEE ACCOUNT (Rev, 02196) EXPENDITURES
STATE PAC COMMITTEES : NOTE : FOR CQP(TRIBLffIONS MADE TO STATEWIDE OR LEGISLATIVE
CANDIDATES . LIST THE CANDIDATE IDENTIFICATION NUMBER IN THE DESIGNATED COLUMN AND THE E] CHECK THIS 13OX IF
PAC CHECK NUM13Fr,R F4 .JR EAr, H EXPENDITURE. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA AMENDING FORM
ETHICS is CAMPAIGN DISCLOSURE : BOARD.

FGQMMITTE:E -~AME (AQu ;:t be same as on Statement of Organization)

DistricL Union 431, UFCW, Political Action Account
CAN0I0A~ 1~E NAME AND ADDRESS TO WHOM EXPENDITURE PURPOSE AMOUNT
DATE ID NUMBER (Disbursement) WAS MADE (CANDIDATES SEE EXPENDED
EX PEN()E1) (if pptis:i!;4~ :) BELOW & ENTER
(MWDDIYR) AND PAC; 1,2,3)

CFIF:;t;,1< NUMB E R

,) S73 1 6. 1b#. ,oc Island o . W)em ntr Comm contrib . 011A010

P O Box 3128
C,K 5
:iii1 Rock Island IL 01204 ( )

CEj;

CK;t ( )

CK1,`

CKid

CK#

G, K~( ( )

SUBTOTAL

TOTAL (if last page of this schedule)

FTH1,5 f3o~ AFPLIES - TA-CANDIDATES' COMMITTEES ONLY :

Campaign funds may be. used only tqr

(1) Eampaign purpo yes .
(_n) constituency expenses, and
(3) vducational and other expenses associated with duties of office .

PIcaw insert trio applicable numb~~r in the purpose column for each expenditure .

Purchasws of cortam campaign property costinrd 5500 or more must also bP inventoried on Schedule H, (Refer to Schedule H Instn.)etions .)

FxpcnddurC4 to perswislenftiL$ providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized on
Scrieduli2 G by the ar'VIOUnt, purpose, and date of each type of expenditure made by the persoNentity on behalf of the candidate's committee . (Refer to
Scr,udule G In±.;ructi,~rl Yn,)d lowo Cod e 56 .fi(3)(i) .)

Page of
!for Schedule B)