- 1t)D ; !11 d 6-0 ~4' JD .

-7
FOR INSTRUCTIONS, SEE BACK OF FORM FORM

DISCLOSURE SUMMARY PAGE DR-2 I DISCLOSURE

(Rev . 12/2005) REPORT
COMMITTEE NAME (Must be same as on Statement of Organization

For Office Use Only

Hy-Vee, Inc. Employees' Political Action Committee Comm . #

IMPORTANT: Indicate by # type of committee you are reporting for: U Logged In ~Mll
( 1 )Statewide/Legislative/Judge Standing for Retention Candidate ( 2 )State PAC ( 3 )State Party
Scanned
( 4 )County Central Committee ( 5 )County Candidate ( 6 )City Candidate (7 )School Board or Other
Political Subdivision Candidate ( 8 )County PAC ( 9 )City.PAC "(1U0 chool Board or Other Political Computer
Subdivision PAC ( 11 ) Loca l Ballot Issue e
Audited
CANDIDATE COMMITTEES ONLY :

Candidate Name ~olitical Party (if applicable) File with :

Iowa Ethics and Campaign
Disclosure Board
Office Sought ! ,1_1511trict (if Senate or House) 510 E. 12'", Ste. 1A
Des Moines, Iowa 50319
Fax: 515-281-3701
Late reports are subject to possible civil and criminal penalties. Pursuant to Iowa Code section 68B.32A(7)
the candidate, f candidate's,c o ifee, and the chai erson, for any other type of committee, is the
indi4dual resp si le for flinq nd accurate repo~ts. 1

POI
l4:-
N REPORT
~ iYyL
TELEPHONE
2-291Y ,5/", , -/
DATIt SIGNED
r6
I AM FILING A May 14, 2006 REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR .

(report date) Indicate by #

CHECK IF AMENDMENT TO REPORT DATED Local Committees, enter Date of Election

0 Check if this is final (termination) report and attach Notice of Dissolution Form DR-3 . County & Local Committees, enter County in
(You must continue to file reports until a DR-3 is filed.) which Election is held

STATEMENT OF CASH ON HAND

CASH ON HAND at the beginning of the reporting period . (Total of all funds held by the
committee. This amount MUST be the same as the cash on hand at the end
29,542 .02
of the last reporting period or must be zero if this is first report filed .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

ADD TOTAL MONEY TAKEN IN THIS PERIOD

12,023 .37
Schedule A: Cash Contributions total (Attach Schedule A) (*also see in-kind below). . . . . . . . . . . . . . . . . . . . . . . . .

Schedule F: Loans Received total (Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .

Schedule H: Total Sales of Campaign Property (Attach Schedule H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(Schedule H applies to Candidates' Committees Only)

SUB-TOTAL. . . . . . . .... . . . . . . .. . . . . $ 41,595 .39

SUBTRACT TOTAL MONEY SPENT THIS PERIOD

Schedule B: Expenditures total (Attach Schedule B) (**also see debts and loans below) . . . . . . . . . . . . . . . . . . 2, 015.00

Schedule F: Loan Repayments total (Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CASH ON HAND at the end of this reporting period (iffinal report balance must
39,550 .39
be zero) (Attach DR-3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

**UNPAID BILLS (From Schedule D - Attach Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 0.00

*IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedule E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 0.00

0.00
**OUTSTANDING LOANS (From Schedule F - Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

CONSULTANT BREAKDOWN(Schedule G Attached?) -YES J NO

CANDIDATE COMMITTEES ONLY:

$ 0 .00
VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H)

STATE COMMITTEES : Submit a reconciled campaign account bank statement in January of each year.
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Gary Adams
14260 Sprague Circle
CK# n/a Omaha, NE 68164 None 50 .00

01/01/06 to 05/14/06 ID# n/a John Amos

801 E Harvest Dr
CK# n/a Mt . Pleasant, la 52641 None 50 .00

01/01/06 to 05114/06 ID# n/a Rick Anderson

1911 Gethmann Lane
CK# n/a Marshalltown, IA 50158 None 50 .00

01/01/06 to 05/14/06 ID# n/a B T Annan

16426 Manderson St
CK# n/a Omaha, NE 68116 None 50 .00

01/01106 to 05/14/06 ID# n/a Christopher Arnold

3402 Monticello
CK# n/a Waterloo, IA 50702 None 50 .00

01/01/06 to 05/14/06 ID# n/a Duane Asche

27410 50th Ave
CK# n/a Dixon, la 52745 None 100 .00

01/01/06 to 05/14/06 ID# n/a Michael Auderer

11944 118th Ave .
CK# n/a Ottumwa, IA 52501 None 16 .67

01101/06 to 05/14/06 ID# n/a Dennis Ausenhus

2854 NE 96th Street
CK# n/a Ankeny, IA 50021 None 50 .00

01/01/06 to 05/14/06 ID# n/a Dave Bailie

5864 Meadow Valley Court
CK# n/a West Des Moines IA 50266 None 50 .00

01/01/06 to 05/14/06 ID# n/a Bruce Bain

505 Grove Ave .
CK# n/a Corning, IA 50841 None 10 .00

SUB-TOTAL 476 .67

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the >
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page / Of
marriage) (See Page 2 of forms packet .) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
forany commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE" RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Stephen Barak
8796 Deer Crest Dr.
CK# n/a Cedar Rapids, IA 52411 None 10 .00

01/01/06 to 05/14/06 ID# n/a Alien Barwick

5640 Twin Cr . Dr.
CK# n/a Pleasant Hill, la 50327 None 60 .00

01/01106 to 05/14/06 ID# n/a Darren Baty

7531 Garland
CK# n/a Lincoln, NE 68505 None 10 .00

01/01/06 to 05/14/06 I D# n/a David Beach

2423 McMullin Dr .
CK# n/a Oskaloosa, IA 52577 None 30 .00

01/01/06 to 05/14/06 ID# n/a Mike Beals

1204 S . 3rd Ave .
CK# n/a Indianola, la 50125 None 25 .00

01/01/06 to 05/14/06 ID# n/a Bernard Beary

5717 Wentworth Dr
CK# n/a Johnston IA 50131 None 50 .00

01/01/06 to 05/14/06 ID# n/a Bonnie Bell

132 27th Court
CK# n/a West Des Moines, IA 50265 None 80 .00

01/01/06 to 05/14/06 ID# n/a Charles Bell

12443 Douglas Parkway
CK# n/a Urbandale, IA 50323 None 100 .00

01/01/06 to 05/14/06 ID# n/a Thomas Benoit

241 New Salem
CK# n/a Canton, IL 61520 None 60 .00

01/01/06 to 05/14/06 ID# n/a Steven Bindseil

8011 North Spruce Ave .
CK# n/a Kansas City, Mo 64119 None 50 .00

I
SUB-TOTAL 475 .00

TOTAL (if last page of this schedule)

Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page-Of__2
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
foranycommercial purpose by anyperson other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Jason Bishop
1106 North Main Street
CK# n/a Mt . Pleastant, la 52641 None 70 .00

01/01/06 to 05/14/06 ID# n/a Paul Boisjolie

87854 Hwy 251
CK# n/a Austin, MN 55912 None 120.00

01/01/06 to 05/14/06 ID# n/a Jennifer Book

1050 68th Street Apt #4
CK# n/a West Des Moines, IA 50266 None 50 .00

01/01/06 to 05/14/06 ID# n/a Thomas Boubin

9360 Kingman Drive
CK# n/a West Des Moines, IA 50266 None 50 .00

01/01/06 to 05/14/06 ID# n/a David Brainard

3996 High St
CK# n/a West Des Moines, IA 50265 None 50 .00

01/01/06 to 05/14/06 ID# n/a Mark Brauer

1466 NW 96th Street
CK# n/a Clive, IA 50325 None 42 .50

01/01/06 to 05/14/06 ID# n/a John Brehm

1209 S 52nd St . #1104
CK# n/a West Des Moines, IA 50265 None 25 .00

01/01/06 to 05/14/06 ID# n/a John Briggs

8 Sugar Creek Lane
CK# n/a Waukee IA 50263 None 50 .00

01/01/06 to 05/14/06 ID# n/a Jon Broce

510 Lakeside Manor Drive
CK# n/a Kirksville, MO 63501 None 50 .00

01/01/06 to 05/14/06 ID# n/a Denise Broderick

6001 Creston Ave #24
CK# n/a Des Moines, IA 50321 None 10 .00

I
SUB-TOTAL 517.50

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the

committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page `~ Of

marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)

familial relationship, enter "not applicable" in the relationship column .

For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a John Brummit
310 Parkview Drive
CK# n/a Waukee, IA 50263 None 25 .00

01/01/06 to 05/14/06 ID# n/a Tim Bruzek

1409 13th Ave W
CK# n/a Spencer, la 51301 None 25 .00

01/01/06 to 05/14/06 ID# n/a Kurrt Buffington

1227 Knollcrest Drive
CK# n/a Fort Dodge, IA 50501 None 20 .00

01/01/06 to 05/14/06 ID# n/a Billy Bulman

100 Lakeview Drive
CK# n/a Colona, IL 61241 None 200.00

01/01/06 to 05/14/06 ID# n/a Steve Busch

1321 Lake Manor Dr.
CK# n/a Trenton, MO 64683 None 50 .00

01/01/06 to 05/14/06 ID# n/a Kenneth Butcher

716 NE 44th CT
CK# n/a Ankeny IA 50021 None 150.00

01/01/06 to 05/14/06 ID# n/a Randy Calhoun

6570 Pelican Drive #201
CK# n/a Osage Beach, MO 65065 None 50 .00

01/01/06 to 05/14/06 ID# n/a Jeffrey Canfield

2209 Stonebrook Dr .
CK# n/a Muscatine, la 52761 None 30 .00

01/01106 to 05/14/06 ID# n/a James Carney

700 Lincoln Rd
CK# n/a Storm Lake, IA 50588 None 50 .00

01/01/06 to 05/14/06 ID# n/a Wade Chalstrom

436 Primrose Dr .
CK# n/a Hudson, la 50643 None 100.00

SUB-TOTAL 700.00

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page_~_Of_Zj
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 688.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person otherthan statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Kwok Chow
10300 Clark
CK# n/a Clive, IA 50325 None 25 .00

01/01/06 to 05/14/06 ID# n/a Mike Christensen

1215 East Van Buren
CK# n/a Washington IA 52353 None 120 .00

01/01/06 to 05/14/06 ID# n/a Dennis Clifton

906 Maple
CK# n/a Albany MO 64402 None 50 .00

01/01/06 to 05/14/06 ID# n/a Kent Cole

16 Julianne Drive NW
CK# n/a Cedar Rapids, IA 52405 None 70 .00

01/01/06 to 05/14/06 ID# n/a Meri Coles

15208 Woodcrest Drive
CK# n/a Clive, IA 50325 None 40 .00

01/01/06 to 05/14/06 ID# n/a Ron Coles

15208 Woodcrest Drive
CK# n/a Clive, IA 50325 None 25 .00

01/01/06 to 05/14/06 ID# n/a Ruth Comer

174 Evergreen Place
CK# n/a West Des Moines, IA 50265 None 25 .00

01/01/06 to 05/14/06 ID# n/a Paula Correy

5620 S Jersey Tess Dr
CK# n/a Sioux Falls, SD 57108 None 41 .65

01/01/06 to 05/14/06 ID# n/a Janet Crocker

605 SE Delaware
CK# n/a Ankeny, IA 50021 None 83 .35

01/01/06 to 05/14/06 ID# n/a Jeff Deahr

1106 10th Street SW
CK# n/a Humboldt, IA 50548 None 60 .00

SUB-TOTAL 540 .00

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PACID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Allen Delaney
2109 SE Briar Den Court
CK# n/a Sioux Falls, SD 57108 None 100.00

01/01/06 to 05/14/06 ID# n/a Douglas Dell

655 Park Ave
CK# n/a Brookings SD 57006 None 100.00

01/01/06 to 05/14/06 ID# n/a Christopher Desaulniers

1418 SE Rio Dr
CK# n/a Ankeny, IA 50021 None 60 .00

01/01/06 to 05/14/06 ID# n/a Greg Dillavou

1701 Meadow Lark Circle
CK# n/a Lincoln, NE 68521 None 60 .00

01/01/06 to 05/14/06 ID# n/a AI Dix

2165 Port Talbot Place
CK# n/a Coralville, IA 52241 None 60 .00

01/01/06 to 05/14/06 ID# n/a William Donahoo

204 N Taylor
CK# n/a Mason City, IA 50401 None 50 .00

01/01/06 to 05/14/06 ID# n/a Charles Donnelly

12532 Rugby Ct
CK# n/a Dubuque, IA 52002 None 100.00

01/01/06 to 05/14/06 ID# n/a Douglas Dop

141 Crestview Drive
CK# n/a Burlington, IA 52601 None 50 .00

01/01/06 to 05/14/06 ID# n/a Becky Dorr

9110 Carpenter Circle
CK# n/a Clive, IA 50325 None 35 .00

01/01/06 to 05/14/06 ID# n/a Melissa Drahelm

2617 Kings Pointe SW
CK# n/a Quincy, II 62305 None 50 .00

SUB-TOTAL 665.00

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no
familial relationship, enter "not applicable" in the relationship column .
 For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person otherthan statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE" RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Donald Drake
811 Wild Rose Rd
CK# n/a Wilton, IA 52778 None 10 .00

01/01/06 to 05/14/06 ID# n/a John Drish

3245 Lundy Lane
CK# n/a Bettendorf IA 52722 None 90 .00

01/01/06 to 05/14/06 ID# n/a Christian Dyhrkopp

11203 N . Wallace
CK# n/a Kansas City, MO 64157 None 25 .00

01/01/06 to 05/14/06 ID# n/a Bradley Dykes

807 Hillcrest Grand Ave .
CK# n/a Yankton SD 57078 None 100 .00

01/01/06 to 05/14/06 ID# n/a Helen Eddy

209 So 27th Street
CK# n/a West Des Moines IA 50265 None 75 .00

01/01/06 to 05/14/06 ID# n/a Randy Edeker

2955 Belfry Dr SW
CK# n/a Waukee, IA 50263 None 125 .00

01/01/06 to 05/14/06 ID# n/a Jeffrey Eslick

7604 NE 86th Street
CK# n/a Kansas City, MO 64157 None 60 .00

01/01/06 to 05/14/06 ID# n/a Terry Evans

535 Midlothian Blvd .
CK# n/a Waterloo, IA 50701 None 120 .00

01/01/06 to 05/14/06 ID# n/a Joel Flug

201 Oakwood Circle
CK# n/a Waverly, la 50677 None 60 .00

01/01/06 to 05/14/06 ID# n/a Theresa Forbes

1609 5th Ave . SW
CK# n/a Altoona, IA 50009 None 10 .00

I
SUB-TOTAL 675 .00

TOTAL (if last page of this schedule)

Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the i
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page Of
marriage) (See Page 2 of forms packet .) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
 For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 688.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person otherthan statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Greg Frampton
1662 NW 122nd Street
CK# n/a Clive, IA 50325 None 50 .00

01/01/06 to 05/14/06 ID# n/a Jamie Franck

86 Pheasant Ave
CK# n/a Atkins, IA 52206 None 50 .00

01/01/06 to 05/14/06 ID# n/a Mary Fuhrman

12307 Izard St
CK# n/a Omaha, NE 68154 None 40 .00

01/01/06 to 05/14/06 ID# n/a Richard Fyock

912 James Ridge
CK# n/a Creston, IA 50801 None 50 .00

01/01/06 to 05/14/06 ID# n/a Thomas Gard

4715 Clemens Blvd
CK# n/a Ames, IA 50014 None 30 .00

01/01/06 to 05/14/06 ID# n/a Kevin Gifford

1111 Raphine Circle
CK# n/a Rhodes, IA 50234 None 50 .00

01/01/06 to 05/14/06 ID# n/a William Glosser

3400 SW 34th Street
CK# n/a Des Moines, IA 50320 None 25 .00

01/01/06 to 05/14/06 ID# n/a Gary Goodhall

2710 NW 161st
CK# n/a Clive, IA 50325 None 20 .00

01/01/06 to 05/14/06 ID# n/a Jeremy Gosch

2924 S . Olive St
CK# n/a Sioux City, IA 51106 None 50 .00

01/01/06 to 05/14/06 ID# n/a Tonya Graff

2821 Country Club Drive
CK# n/a Atlantic, IA 50022 None 30 .00

SUB-TOTAL

I
395 .00

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the

committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page tOf~
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD .

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Terry Graybill
532 Bailey Court
CK# n/a Cherokee, IA 51012 None 30 .00

01/01/06 to 05/14/06 ID# n/a John Green

1221 Rushridge
CK# n/a Jefferson, IA 50129 None 100 .00

01/01/06 to 05/14/06 ID# n/a Jeff Grell

435 Deborah Ave
CK# n/a Fremont, NE 68025 None 75 .00

01/01/06 to 05/14/06 ID# n/a David Grond

6060 N Forest Dr.
CK# n/a Parkville, MO 64152 None 30 .00

01/01/06 to 05/14/06 ID# n/a Shelley Haberkorn

317 SE 8th
CK# n/a Ankeny, IA 50021 None 50 .00

01/01/06 to 05/14/06 ID# n/a Kevin Halbmaier

P 0 Box 205
CK# n/a Albia, IA 52531 None 50 .00

01/01/06 to 05/14/06 ID# n/a Mark Halbmaier

208 Aurora
CK# n/a Boone, IA 50036 None 50 .00

01/01/06 to 05/14/06 ID# n/a Marcus Hall

1219 West 15th St . South
CK# n/a Newton, IA 50208 None 150 .00

01/01/06 to 05/14/06 ID# n/a Dennis Hartogh

6109 Willow Brook Dr .
CK# n/a Asbury, IA 52002 None 70 .00

01/01/06 to 05/14/06 ID# n/a Tim Haupert

5268 T Ave
CK# n/a Cherokee, IA 51012 None 50 .00

I
SUB-TOTAL 655 .00

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Patrick Hensley
17938 Bent Tree Ridge
CK# n/a Council Bluffs, IA 51503 None 41 .70

01/01/06 to 05/14/06 ID# n/a Roger Hepler

714 Stevens Street
CK# n/a Iowa Falls, la 50126 None 60 .00

01/01/06 to 05/14/06 ID# n/a Christopher Higginbotham

2710 Tara Hills St
CK# n/a Council Bluffs, IA 51503 None 49 .98

01/01/06 to 05/14/06 ID# n/a Brent Highfill

9805 Skyline Circle
CK# n/a Johnston, la 50131 None 100 .00

01/01/06 to 05/14/06 ID# n/a Curtis Hill

609 SW 15th Terrace
CK# n/a Lee's Summit, MO 64081 None 50 .00

01/01/06 to 05/14/06 ID# n/a Darin Hirl

1616 Parkhill Drive
CK# n/a Norwalk, IA 50211 None 50 .00

01/01/06 to 05/14/06 ID# n/a Cindy Hoch

1009 East Henderson Place
CK# n/a Indianola, IA 50125 None 70 .00

01/01/06 to 05/14/06 ID# n/a Dwight Hoch

52172 Hwy 14
CK# n/a Chariton, IA 50049 None 40 .00

01/01/06 to 05/14/06 ID# n/a Tod Hockenson

503 Craig Drive
CK# n/a Cherokee, IA 51012 None 25 .00

01/01/06 to 05/14/06 ID# n/a Lisa Hoppman

881 Sunnyview Ave .
CK# n/a Knoxville, IL 61448 None 20 .00

SUB-TOTAL 506 .68

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page_Z!~__Of
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE: IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Michael Hoppman
2001 12th St
CK# n/a Eldora, IA 50627 None 30 .00

01/01/06 to 05/14/06 ID# n/a Kevin Hormann

704 Augusta Dr . SE
CK# n/a Cedar Rapids, IA 52403 None 60 .00

01/01/06 to 05/14/06 ID# n/a Freddie Housman

1105 Mallory Lane
CK# n/a Chariton IA 50049 None 100 .00

01/01/06 to 05/14/06 ID# n/a Greg Hull

14289 Elmcrest Ct
CK# n/a Clive, IA 50325 None 50 .00

01/01/06 to 05/14/06 ID# n/a Mary Hunter

13061 Clark St .
CK# n/a Clive, IA 50325 None 25 .00

01/01/06 to 05/14/06 ID# n/a Kurt Johnson

6509 Foxrun Dr .
CK# n/a Cedar Rapids, IA 52404 None 25 .00

01/01/06 to 05/14/06 ID# n/a Blane Jones

324 NE Woodbury Dr.
CK# n/a Lee's Summit, MO 64086 None 50 .00

01/01/06 to 05/14/06 ID# n/a Richard Jurgens

3008 Jordan Grove
CK# n/a West Des Moines IA 50265 None 500 .00

01/01/06 to 05/14/06 ID# n/a Tracy Kading

2155 Country Club Drive
CK# n/a Mason City, IA 50401 None 60 .00

01/01/06 to 05/14/06 ID# n/a Meredith Kavanagh

55034 150th Ave
CK# n/a Lucas, IA 50151 None 25 .00

SUB-TOTAL 925 .00

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page / Of
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE. IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a William Kittler
401 S. Jefferson
CK# n/a New Ulm, MN 56073 None 50 .00

01/01/06 to 05/14/06 ID# n/a Rose Kleyweg Mitchell

5707 Pommel Court
CK# n/a West Des Moines, IA 50266 None 150.00

01/01/06 to 05/14/06 ID# n/a Jane Knaack-Esbeck

715 51 st Street
CK# n/a Des Moines, Iowa 50312 None 75 .00

01/01/06 to 05/14/06 ID# n/a Jennifer Kopriva

1632 Mackin Dr
CK# n/a Dewitt, la 52742 None 60 .00

01/01/06 to 05/14/06 ID# n/a Karl Kruse

8021 Tiburon PI
CK# n/a Johnston, IA 50131 None 20 .00

01/01/06 to 05/14/06 ID# n/a Randy Kruse

1413 6th St NE
CK# n/a Waseca, MN 56093 None 50 .00

01/01/06 to 05/14/06 ID# n/a Michael Kueny

7087 Hillcrest Court
CK# n/a Johnston, IA 50131 None 30 .00

01/01/06 to 05/14/06 ID# n/a Carey Lenning

6001 Creson Ave #24
CK# n/a Des Moines, IA 50321 None 25 .00

01/01/06 to 05/14/06 ID# n/a Robert Lewin

207 Manor Dr
CK# n/a Osceola, IA 50213 None 20 .00

01/01/06 to 05/14/06 ID# n/a James Lingo

2535 Heatherview Circle
CK# n/a Marion, IA 52302 None 20 .00

I
SUB-TOTAL 500.00

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the -7
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page 2- Of G
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION : Section 68B .32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Michael Long
2022 Willowview Ln
CK# n/a Rochester, MN 55902 None 60 .00

01/01/06 to 05/14/06 ID# n/a John Lonning

9260 N .W . 36th Street
CK# n/a Polk City, IA 50226 None 150 .00

01/01/06 to 05/14/06 ID# n/a Matthew Ludwig

1110 Lamplighter Ln
CK# n/a Lincoln, NE 68510 None 33 .34

01/01/06 to 05/14/06 ID# n/a Mike Magnuson

401 SE 8th Street
CK# n/a Ankeny, IA 50021 None 50 .00

01/01/06 to 05/14/06 ID# n/a David Martin

4860 Waterford Dr .
CK# n/a West Des Moines, IA 50265 None 10 .00

01/01/06 to 05/14/06 ID# n/a Anthony McCann

179 59th St
CK# n/a West Des Moines, IA 50266 None 100 .00

01/01/06 to 05/14/06 ID# n/a Gary McClure

615 Green Valley Terr .
CK# n/a Cedar Rapids IA 52403 None 60 .00

01/01/06 to 05/14/06 ID# n/a Mark Mc Quistan

3401 SW Court Ave .
CK# n/a Ankeny, IA 50021 None 50 .00

01/01/06 to 05/14/06 ID# n/a Steve Mescher

306 19th St SE
CK# n/a Cedar Rapids, IA 52403 None 10 .00

01/01/06 to 05/14/06 ID# n/a Mark Millsap

18330 W. 160th Terrace
CK# n/a Olathe, KS 66062 None 125 .00

SUB-TOTAL 648 .34

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page _(_jOf
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
foranycommercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Steve Mokosak
8214 W . 127th Place
CK# n/a Overlandpark, KS 66212 None 30 .00

01/01/06 to 05/14/06 ID# n/a Brian Moon

159 Norwood Dr .
CK# n/a Council Bluffs IA 51503 None 100 .00

01/01/06 to 05/14/06 ID# n/a James Moore, Jr.

46723 235th Trail
CK# n/a Chariton, IA 50049 None 20 .00

01/01/06 to 05/14/06 ID# n/a Christy Myers

14949 73rd Ave .
CK# n/a Indianola, IA 50125 None 25 .00

01/01/06 to 05/14/06 ID# n/a Andrew Nielsen

9401 Hickory Dr
CK# n/a Urbandale, IA 50322 None 100 .00

01/01/06 to 05/14/06 ID# n/a Pat Ohlerking

1206 Clark St .
CK# n/a Charles City, IA 50616 None 20 .00

01/01/06 to 05/14/06 ID# n/a Dan Olson

2220 Aspen Lane
CK# n/a North Mankato, MN 56003 None 100 .00

01101/06 to 05/14/06 ID# n/a John Olson

612 Durham Court
CK# n/a Lawrence, KS 66049 None 41 .67

01/01/06 to 05/14/06 ID# n/a Charles Osborn

355 Forest Lane N .
CK# n/a Elgin, MN 55932 None 50 .00

01/01/06 to 05/14/06 ID# n/a Charles Osmanski

1001 South Street
CK# n/a Webster City, IA 50595 None 13 .34

SUB-TOTAL 500 .01

II '
TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the L
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page

marriage) (See Page 2 of forms packet .) . If surname of contributor is the same as candidate, but there is no (for Schedule A)

familial relationship, enter "not applicable" in the relationship column .

For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev . 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements forsoliciting contributions or
forany commercial purpose by any person other than statutory political committees.

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Curtis Osmanski
411 Albion Ave.
CK# n/a Fairmont, MN 56031 None 40 .00

01/01/06 to 05/14/06 ID# n/a Michael O'Tool

1558 303rd Ave .
CK# n/a Ft Madison IA 52627 None 30 .00

01/01/06 to 05/14/06 ID# n/a Mark Parker

18632 Anne Street
CK# n/a Omaha, NE 68135 None 10 .00

01/01/06 to 05/14/06 ID# n/a Matthew Parkhurst

1309 Cottonwood Dr .
CK# n/a Greenwood, MO 64034 None 50 .00

01/01/06 to 05/14/06 ID# n/a John Peterman

62 Schwartz Dr.
CK# n/a Ottumwa, IA 52501 None 19 .96

01/01/06 to 05/14/06 ID# n/a Jon Peterson

7205 Brookdale Lane NE
CK# n/a Cedar Rapids, IA 52402 None 20 .00

01/01/06 to 05/14/06 ID# n/a James Phinney

18510 290th Road
CK# n/a Unionville MO 63565 None 60 .00

01/01/06 to 05/14/06 ID# n/a Ronald Pickel

1740 Juniper Ln SW
CK# n/a Rochester, MN 55902 None 50 .00

01/01/06 to 05/14/06 ID# n/a Mark Pullen

5401 SW 19th St.
CK# n/a Des Moines, IA 50315 None 30 .00

01/01/06 to 05/14/06 ID# n/a Jeff Quandt

2411 Ridge Point Circle
CK# n/a Lincoln, NE 68512 None 30 .00

SUB-TOTAL 339 .96

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
Z
.
f
Of
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page '

marriage) (See Page 2 of forms packet .) . If surname of contributor is the same as candidate, but there is no (for Schedule A)

familial relationship, enter"not applicable" in the relationship column .

 For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ J CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person otherthan statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE' RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a David Rasmussen
150 Circle Dr .
CK# n/a Galesburg, IL 61401 None 30 .00

01/01/06 to 05/14/06 ID# n/a Kevin Reeve

703 N 11th
CK# n/a Chariton, IA 50049 None 20 .00

01/01/06 to 05/14/06 ID# n/a Rodney Rogotzke

2504 Fairview
CK# n/a Chillicothe, MO 64601 None 25 .00

01/01/06 to 05/14/06 ID# n/a Brian Rose

511 Indian Trail Rd
CK# n/a Ottumwa, la 52501 None 75 .00

01/01/06 to 05/14/06 ID# n/a Scott Schlatter

5932 S. 81 st St .
CK# n/a Lincoln, NE 68516 None 50 .00

01/01/06 to 05/14/06 ID# n/a Dan Schmedding

216 Chancery Lane
CK# n/a Mankato, MN 56001 None 100.00

01/01/06 to 05/14/06 ID# n/a James Scott

4501 99th Street
CK# n/a Urbandale, IA 50322 None 150.00

01/01/06 to 05/14/06 ID# n/a Tom Settle

684 62nd Street
CK# n/a West Des Moines, IA 50266 None 50 .00

01/01/06 to 05/14/06 ID# n/a Alan Shank

702 Aldrich Dr
CK# n/a Northfield, MN 55057 None 60 .00

01/01/06 to 05/14/06 ID# n/a Kevin Sherlock

2495 Grey Wolf
CK# n/a Hiawatha, IA 52233 None 120.00

SUB-TOTAL 680.00

TOTAL (if last page of this schedule) I

' Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page
16Of
z I
marriage) (See Page 2 of forms packet .) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev . 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN. A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibitsthe use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Richard Shipley
3201 Crystal Drive
CK# n/a Burlington, IA 52601 None 60 .00

01/01/06 to 05/14/06 ID# n/a James Siemens

974 Spooner Dr .
CK# n/a Watertown, SD 57201 None 10 .00

01/01/06 to 05/14/06 ID# n/a Ken Simmons

211 Winsor Way
CK# n/a Sergeant Bluff, IA 51051 None 16 .66

01/01/06 to 05/14/06 ID# n/a Mike Skokan

501 52nd Street
CK# n/a West Des Moines, IA 50265 None 125 .00

01/01/06 to 05/14/06 ID# n/a Traci Slaybaugh

4920 N . 142th St .
CK# n/a Omaha, NE 68164 None 150 .00

01/01/06 to 05/14/06 ID# n/a Eric Smith

2945 220th St
CK# n/a Winterset, IA 50273 None 25 .00

01/01/06 to 05/14/06 ID# n/a Lewis Snook

1004 Waterfront Drive
CK# n/a Ankeny, la 50023 None 200 .00

01/01/06 to 05/14/06 ID# n/a Nicholas Steinbach

21938 Trailridge Blvd
CK# n/a Elk Horn, NE 68022 None 150.00

01/01/06 to 05/14/06 ID# n/a Bill Stepanek

3055 Brittany Circle
CK# n/a Cedar Rapids, IA 52411 None 50 .00

01/01/06 to 05/14/06 ID# n/a Ken Stephens

808 West Main
CK# n/a Cherokee, IA 51012 None 40 .00

SUB-TOTAL 826 .66

TOTAL (if last page of this schedule) I

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the L
- r
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page ( 2Of
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev . 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person otherthan statutory political committees .

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE' RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Nathan Stewart
5201 Lakecrest Dr.
CK# n/a Shawnee, KS 66218 None 50 .00

01/01/06 to 05/14/06 ID# n/a Ray Stewart

12864 Clark Street
CK# n/a Clive, IA 50325 None 100.00

01/01/06 to 05/14/06 ID# n/a Mike Stoermer

540 Auburn Hills Drive
CK# n/a Coralville, IA 52241 None 30 .00

01/01/06 to 05/14/06 ID# n/a Andrew Streit

344 S. 48th St .
CK# n/a West Des Moines, IA 50265 None 25 .00

01/01/06 to 05/14/06 ID# n/a Matthew Streit

209 Woodchuck Ln
CK# n/a Macomb, IL 61455 None 40 .00

01/01/06 to 05/14/06 ID# n/a Kim Strub

324 Broadmoore
CK# n/a South Sioux City, Ne 68776 None 8.39

01/01/06 to 05/14/06 ID# n/a Timothy Stupka

801 Inverness Drive
CK# n/a Sioux Falls, SD 57108 None 50 .00

01/01/06 to 05/14/06 ID# n/a Jeff Suchomel

406 West Street
CK# n/a Shenandoah, IA 51601 None 20 .00

01/01/06 to 05/14/06 ID# n/a Tim Sullivan

1322 Street F-32
CK# n/a Harlan IA 51537 None 26 .66

01/01/06 to 05/14/06 ID# n/a Cynthia Sulzman

906 Meadowbrook Dr.
CK# n/a Kearney, MO 64060 None 215.00

SUB-TOTAL 565.05

TOTAL (if last page of this schedule)

Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page Of
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements forsoliciting contributions or
for any commercial purposeby any person other than statutory political committees.

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE' RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Randy Summerville
4516 SW Raintree Shore Dr.
CK# n/a Lee's Summit MO 64082 None 50 .00

01/01/06 to 05/14/06 ID# n/a Suzi Sundholm

2604 E . 35th St . Ct .
CK# n/a Davenport, IA 52807 None 50 .00

01/01/06 to 05/14/06 ID# n/a Ronald Taylor

555 Westwoods Dr .
CK# n/a Waukee, IA 50263 None 100 .00

01/01/06 to 05/14/06 ID# n/a Robert Teeselink

206 Wood Acres
CK# n/a Algona, IA 50511 None 30 .00

01/01/06 to 05/14/06 ID# n/a Scott Thompson

812 South 1st Ave
CK# n/a Iowa City, IA 52245 None 60 .00

01/01/06 to 05/14/06 ID# n/a Robert Trader

709 South Outlook Dr .
CK# n/a Sioux Falls, SD 57106 None 100 .00

01/01/06 to 05/14/06 ID# n/a Tom Twohill

1508 Lone Oak Circle
CK# n/a Fairfiield, IA 52556 None 30 .00

01/01/06 to 05/14/06 ID# n/a Keith Van Gent

720 22nd Ave
CK# n/a Sheldon, IA 51201 None 50 .00

01/01/06 to 05/14/06 ID# n/a Randy Vanderleest

1312 Belaire
CK# n/a Polk City, IA 50226 None 20 .00

01/01/06 to 05/14/06 ID# n/a Phillip Walker

15808 W 126th Terrace
CK# n/a Olathe KS 66062 None 50 .00

SUB-TOTAL 540 .00

TOTAL (if last page of this schedule)

" Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the .-Z (

committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page ~~ Of

marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)

familial relationship, enter "not applicable" in the relationship column .

For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ ] CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
for any commercial purpose by any person other than statutory political committees.

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE* RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Ken Waller
8024 Tiburon Place
CK# n/a Johnston, IA 50131 None 62 .50

01/01/06 to 05/14/06 ID# n/a Thomas Watson

8100 Heather Bow Crt
CK# n/a Johnston, IA 50131 None 100 .00

01/01/06 to 05/14/06 ID# n/a James Watters

1850 Mackenzie Dr .
CK# n/a Cedar Rapids, IA 52411 None 50.00

01/01/06 to 05/14/06 ID# n/a Michael Webb

309 NW 12th Dr
CK# n/a Leon, IA 50144 None 50.00

01/01/06 to 05/14/06 ID# n/a Alan Weisert

1430 Edgewater Dr .
CK# n/a Albert Lea, MN 56007 None 60 .00

01/01/06 to 05/14/06 ID# n/a Jon Wendel

8319 Chambery
CK# n/a Johnston, IA 50131 None 50 .00

01/01/06 to 05/14/06 ID# n/a Sharm Wenndt

3633 E . 59th Court
CK# n/a Davenport, IA 52807 None 30 .00

01/01/06 to 05/14/06 ID# n/a Dennis Wernli

PO Box 339
CK# n/a Woodward, IA 50276 None 25 .00

01/01/06 to 05/14/06 ID# n/a Gregory Wery

6493 Cutler St
CK# n/a Waterloo, la 50703 None 50 .00

01/01/06 to 05/14/06 ID# n/a Jim Wichman

1304 South Tayberry Ave
CK# n/a Sioux Falls, SD 57106 None 50 .00

SUB-TOTAL 527 .50

TOTAL (if last page of this schedule)

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by PageZ Of
marriage) (See Page 2 of forms packet .) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
 For Instructions, See Back of Form
SCHEDULE
CONTRIBUTIONS - MONEY TAKEN IN A MONETARY
(Including candidates's personal funds) (Rev. 02/96) RECEIPTS

COMMITTEE NAME' (Must be same as on Statement of Organization) [ j CHECK THIS BOX IF

AMENDING FORM
HY-VEE, INC . EMPLOYEES' POLITICAL ACTION COMMITTEE
STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST THE PAC IDENTIFICATION
NUMBER AND THE PAC CHECK NUMBER IN THE DESIGNATED COLUMN . A LIST OF ID NUMBERS IS AVAILABLE FROM THE IOWA ETHICS AND CAMPAIGN
DISCLOSURE BOARD.

CAUTION: Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for soliciting contributions or
forany commercial purpose by any person other than statutory political committees.

DATE PAC ID NUMBER NAME AND ADDRESS OF CONTRIBUTOR RELATIONSHIP AMOUNT

(if applicable) TO CANDIDATE' RECEIVED
AND PAC CHECK (if applicable)
NUMBER
01/01/06 to 05/14/06 ID# n/a Monte Wiese
2929 Woodland Hill Dr .
CK# n/a Dallas Center, IA 50063 None 50 .00

01/01/06 to 05/14/06 ID# n/a Don Wilkens

6640 Monticello Court
CK# n/a Johnston, IA 50131 None 75 .00

01/01/06 to 05/14/06 ID# n/a Scott Wilkinson

6335 Sutton Dr .
CK# n/a Urbandale, IA 50322 None 25 .00

01/01/06 to 05/14/06 ID# n/a Lisa Woltman

958 570th St
CK# n/a Cherokee, IA 51012 None 15 .00

01/01/06 to 05/14/06 ID# n/a Randy Wood

354 Ascension Point
CK# n/a Holts Summit, MO 65043 None 50 .00

01/01/06 to 05/14/06 ID# n/a Frank Woodward

7124 Joyce St .
CK# n/a Omaha, NE 68138 None 50 .00

01/01/06 to 05/14/06 ID# n/a Brent Yager

415 S 466th Ave
CK# n/a Vermillion, Sd 57069 None 50 .00

01/01/06 to 05/14/06 ID# n/a Scott Youngberg

3510 Rimrock Dr NE
CK# n/a Cedar Rapids, IA 52402 None 50 .00

01/01/06 to 05/14/06 ID# n/a

CK# n/a None

01/01/06 to 05/14/06 ID# n/a

CK# n/a None

SUB-TOTAL 365 .00

TOTAL (if last page of this schedule) 12,02317

* Disclosure law requires candidate committees to disclose the relationship of any relative making a contribution to the

committee. Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives by Page L ! Of
2
marriage) (See Page 2 of forms packet.) . If surname of contributor is the same as candidate, but there is no (for Schedule A)
familial relationship, enter "not applicable" in the relationship column .
 Use separate scheduws) PAGE OF
the
for each ply
SCHEDULE B ITEMIZED DISBURSEMENTS of
Detailed Summary Page FOR LINE NUMBER

soliciting contributions or for commercial

Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of
political contributions from such committee.
purposes. other than using the name and address of any committee to solicit

NAME OF COMMITTEE (in Full)

Hy-Vee, inc ., Employees' Political Action Committee
Purpose of Disbursement Date (month, Amount of Each
A. Full Nanw Mailing Address and ZI
day, year) Disbursement This Period
`~ L iC

vt ( ~~ Disbursement for:
U
Primary General
000
111,17 ' &7 ~ 5030 Other (specify) ~/
Date month, Amount of Each
9. Fun Name Mailing Address and ZIP Code Purpose of Disbursement
day. year) Disbursement This Period
0"I
.~

Primary General
L( co
( Disbursement for

-e S TA 563 0 9
D ~
Other (specify) .3 iJdt/:

C. Full Mama, Mailing Addressand ZIP Code Purpose of Disbursement Date (month, Amount of Each
~
~w
' day, year) Disbursement This Period
/i /JuKI
! iN e"1 si -+- ~~i c~'~s
O X 3 :31 Disbursement for. Primary General
tJ / 0
C ~N 'fd.t ~/~- 5v o Y Other (specify) ~' S-(
Purpose of Disbursement Date (month, Amount of Each
D. Full Name, Mailing Addressand ZIP Coda
day. year) Disbursement This Period

Disbursement for Primary General

U L
Other (specify)

E. Full Name, Mailing Address and ZIP Code Purpose of Disbursement Date (month, Amount of Each
day, year) Disbursement This Period

Disbursement for. General

L Primary
Other (specify) D
F. Full Name, Mailing Address and ZIP Code Purpose of Disbursement Date (month, Amount of Each
day, year) Disbursement This Period

Disbursement for: L Primary General

U
Other (specify)

G. Full Name, Mailing Address and ZIP Code Purpose of Disbursement Date (month, Amount of Each
day, year) Disbursement This Period

Disbursement for Primary General

Other (specify)
71
H. Full Name, Mailing Address and ZIP Code Purpose of Disbursement Date (month, Amount of Each
day, year) Disbursement This Period

- Disbursement for. Primary

U
General
Other (specify)

1 . Full Name, Mailing Address and ZIP Code Purpose of Disbursement Date (month, Amount ct Each
day, year) Disbursement This Period

Disbursement for Primary General

)Other (specify)

SUBTOTAL of DisbursementsThis Page (optional) . . . . . . . . . . . . . . .. . . . . .. . . . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. .. . . . . . . . . . . . . . .. . ... . . . . . . .. . . . . .. . . ... . . . .

TOTAL This Period last page this line number only)

'ESAN066