07/22/2005 14 :47 FAX 515 282 0318

JUL-22-2005 13=47
GALLIGANDOYLEREID
IA ETHICS CAMPAIGN DISCLO s~l~~alsral r o
O~

Form DR-OTC
IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD
510 EAST 12 TH , SUITE lA
G
ONE-TIME CONTRIBUTION IN
DES MOINES, IA $0310 EXCESS OF 97W BY A
PERMANENT ORGANIZATION
Fax : (515)281-3701
www .iowa-govlethlcs For offtca um 001
indexed
ONE~'71ft CONTRIBUTION IN EXCESS OF $750 Audited
BY A PERMANENT ORGANIZATION Checked
Computer
Iowa Code section 8aA.402(9) requires a permanent organization that contributes in excess of
$750 to register and file reports as a PAC, This form is intended to serve those purposes. T~
form must he ffed with the Board o29-rtW_o ra the tenth dart _ f the date the check was Issued

ORGANIZATION MAKING CONTRIBUTION - '

Name

MSYIng Address City, Stare, Z)p Code

EmailAddress (Optional) Area Code & Telephone No,

CONTACT PERSON FOR THE ORGANIZATION ;

CANDIDATE OR COMMITTEE RECEIVING THE CONTRIBUTION :

T i~'
Narne or Can (date or Commute

Mailing Ad ass Cl1y, State, Zip Coda 1 ~o

Date of Contribubo Amount
S' 2 4?~ : ? 1Z
Email Address (if available) Area Coda & Telephone Number zed
Date of Elwilon Court Of Applicable)

If contribution to candidate, disclose source of original funds used to make

such contribution (attach additional pages if necessary). if In-Idnd ConvIbutlon, Describe

Criteria to use this form:

One campaign conlribution in excess of $750 was made to a state or local oandidets, party, political committee (PAC) tar either a
candidate or a ballot issue, or any other organizelon thai1 advocates the election or defeat of a candidate or ballot Issue .
2. Must be a permanent organization not eetabllshed for election purposes .
3. No person gave money 10 to organization for the purpose of the organzaldon then using the money to make the contribution_
4. if the contribution was made to a candidate, no funds from a corporation or other prohibited cotrMbutor under Iowa Code section
68A.S03 were used to make the contribution (this does not apply to a conifuton made to a ballot Issue committee) .
5. Only one contribution to any campaign eornrntttao except for a ballot issue eomrnittee was made in a calendar year. No more than one
contribution may Ire made to any one bauot issue committee during a ballot lesue election. It more Vim one contribution and the total
amount of the contributions exceed $750. the organization must register with the Board as a political committee (PAC) within 10 days of
crossina the $780 threshold.

Statement of Affl Lion ;

!, affirm shat the contribution reported above Is accurate . t further affirm that the Information concerning the organlzatlon Is
correct and true to the best of my knowledge . I understand that by fling this form, i am subject to the laws found In Iowa Code chapter 68A and
administrative rules found In chapter 361 . 1 also understand Thai the failure to timely file this form loos to the Imposlrion of civil penaltas and the
Intentional failure to file ihg f9rm rryty d to additional civil and criminal sanctions,

' "Contribution" Includes good or services that are provided for free or otherwise less than fair market value.
TOTAL P .02