IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD Form

510 EAST 122 SUITE 1A VERIFIED STATEMENT

REGISTRATION
DES MOINES, IA 50319 (Out-of-State Committees)
www . iowa.gov/ethics (Rev . 03/05)
VERIFIED STATEMENT REGISTRATION For office use oniv
(Out-of-State Committee) Comm . #
Indexed
COMMITTEES NOT ORGANIZED IN IOWA TO COMPLETE IN DUPLICATE .
SEND A COPY TO THE BOARD WITHIN 15 DAYS OF THE CONTRIBUTION DATE AND Audited
ONE COPY WITH EACH CONTRIBUTION TO THE IOWA COMMITTEE WITH THE CONTRIBUTION .
Checked
PLEASE REFER TO DETAILED INSTRUCTIONS ON BACK OF FORM .
THIS FORM MUST BE FILED FOR EACH CONTRIBUTION IN EXCESS OF $50 Computer

COMMITTEE NAME
ffcialhlame f 01st-of- ate Cotnmittee~l~gPpt abt2reylate committee name . Written explanation must be provided for Acronym) .
Iowa $riorittes ~ctton Committee
Mailing Address
P.O. Box 35
City, State, Zip Code Area Code & Telephone No .
Manchester, IA 52057 (319) 621-6425

CONTACT PERSON FOR THE COMMITTEE :

Nick Ryan
N W 5 Ashby Avenue Des Moines, IA 50310
M ~ pg A r ss
ickJTmNussle.com (31 ty6 F-645
Email Address (Optional) Area Code & Telephone Number

Purpose of Committee/Contribution : (Please indicate by checking appropriate box)

"-'Candidate El Ballot Issue PAC El Other PAC n Party (State or Central Committee)
STATE OR FEDERAL JURISDICTION WHERE COMMITTEE PARENT ENTITY, AFFILIATE, SPONSOR OF COMMITTEE
IS REGISTERED OR OPERATES (Use separate page if needed to list more than one entity)
eame of Jurisdiction Name
Federal Election
Mailing Address Mailing Address
999 E Street NW
C1Ur, State, Zip Code, Area Code & Telephone No . City, State, Zip Code
Was ing on, lJ .C.

IOWA RESIDENT AGENT IOWA COMMITTEE RECEIVING CONTRIBUTION

Typed Name of Iowa Resident Name of Committee
Nick Ryan Waukee for McGee
Mailing Address Mailing Address
760 Willowbrook Rd .
4015 Ashby Avenue
City, State, Zip Code Area Code & Telephone No . Date If In-Kind Contribution, Describe
Des Moines, IA 50310 (319) 621-6425 10/31/2005 N/A
Amount
$ 50 .00 lNk # 13493
ttee. ID #

VERIFIED STATEMENT OF COMMITTEE :

1 Nick Ryan , attest that the contribution reported above is accurate and that the information about this out-of-state
ct and accurate to the best of my knowledge. I also attest that the reports filed in the namedjurisdiction comply with requirements
that are
'"'--- a Code section 68A402A6, including the disclosure of all contributions received and all expenditures made. I
further attest that the
s made from an account that does not accept contributions corporations or other prohibited contributors under Iowa Code
cipient committee is a ballot issu mmittee. understand at potential civil and criminal penalties may apply unless a copy
Ethics and Campaign Di re Board wi in 15 days gP a dpte ofjhe contribution.