An $ Z Du: Disclosure Summary Page DR-2
An $ Z Du: Disclosure Summary Page DR-2
U 40 ---I
Office Sought ,, .., District (if Senate or House)
Late reports are subject to possible civil and criminal penalties . Pursuant to Iowa Code section 68B .32A(7) the candidate, for a candidate's committee,
and the chairperson, for any other type of committee, is the individual responsible for filing timely and accurate reports .
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TELEPHONE DATE SIGNED
A MONETARY
CONTRIBUTIONS - MONEY TAKEN IN (Rev. 07/03) RECEIPTS
(Including candidate's personal funds)
CHECK THIS BOX IF
COMMITTEE NAME (Must be same as on Statement of Organization) AMENDING FORM
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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 4 IF FOR
RECEIVED (if applicable) TO CANDIDATE` RECEIVED FUND-
(MM/DD/YR) AND PAC CHECK (if applicable) RAISER
NUMBER INCOME
ID#
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SUB-TOTAL pl)
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TOTAL (if last page of this schedule) M
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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) . If surname of contributor is the same as candidate, but there is no Page -- of
familial relationship, enter "not applicable" in the relationship column . (for Schedule A)
FOR INSTRUCTIONS, SEE BACK OF FORM SCHEDULE
33
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SUB-TOTAL $
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TOTAL (if last page of this schedule) $ cx
Purchases of certain campaign property costing $500 or more must also be inventoried on Schedule H . (Refer to Schedule H instructions .)
Expenditures to persons/entities providing consulting, advertising, fund-raising, polling, managing, organizing services must also be detail itemized on
Schedule G by the amount, purpose, and date of each type of expenditure made by the person/entity on behalf of the candidate's committee . (Refer to
Schedule G instructions and Iowa Code 68A .402(3)(i) .)
Page--I--of- i1-
(for Schedule B)