International_Union_Painters_PAC_Polk_County

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I OWA ETHI CS AND CAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 122 SUI T E 1 ADES MOI NES, I A 5 0 3 1 9www. i o wa . g o v / e t h i c s

N" G, 3 I VERIFIEDSTATEMENTREGISTRATIONCOMMI TTEES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPLI CATE .SEND A COPY TO THE BOARDWI T H I N 1 5 DAYS OF THECONTRI BUTI ON DATE ANDONE COPY WI TH EACH CONTRI BUTI ON TO THE I OWA COMMI TTEE WI TH THE CONTRI BUTI ON .PLEASE REFER TO DETAI LED I NSTRUCTI ONS ON BACK OF FORM .T HI S FORM MUST BE F I L E D FOR EACH CONTRI BUTI ON I N EXCESS OF $ 5 0

COMMI TTEENAMEO f f i c i a l Name o f O u t - o f - S t a t e Co mmi t t e e ( Do n ot a bb r e v i a t e c o mmi t t e e na me . Wr i t t e n e x pl a n at i o n must b e p r o v i d ed f o r Ac r o n y m) .I n t e r n a t i o n a l 1 1 n i o n o f P a i n t e r - , & A l l i e d T r a d e s , P n l i t i r " a l A r t i o n t ' n mmi t t e e

1 7 5 0 New Yo r k A v e n u e , NW Ma i l i n g Ad d r e s sC i t y , S t a t e , Z i p C o d eWa s h i n g t o n , DC 2 0 0 0 6 Ar e a C o d e & T el e p h o n e No .( 2 0 2 ) 6 3 7 - 0 7 0 0

CONTACT PERSON FOR THE COMMI TT EE :

Pu r p o s e o f C o mmi t t e e / C o n t r i b u t i o n : ( P l e a se i n d i c a t e b y c h ec k i n g a p p r o p r i a t e b o x )OCand i d a t e 1 : 1 Ba l l o t I s s ue PAC

STATE ORFEDERALJURI SDI CTI ONWHERECOMMI TT EEI S REGI STERED OROPERATESName o f J u r i s d i c t i o nF e d e r a l E l e c t i o n Commi s s i o n9 9 9 E S t r e e t , NWMa i l i n g Ad d r e s s

C i t S t a t e , Z i p C o d e Ar e a C o d e &T el e p ho n e No .Ws hi n g t o n , DC ( 2 0 2 1 6 94 - 1 1 0 0

NameI n t e r n a t i o n a l Un i o n o f P a i n t e r s & A l l i e d T r a d e sMa i l i n g s s1 7 5 0 New Yo r k A v e n u e ,

Ci t , S t a t e , Z i p C o d eWa s h i n g t o n . DC 2 0 0 6I OWA RESI DENT AGENT

VERI F I ED STATEMENTOF COMMI TTEE:

( O u t - o f - S t a t e Commi t t e e)

Ot he r PAC F1 Pa r t y ( S t a t e o r Ce n t r a l Commi t t e e )

I OWA COMMI TTEE RECEI VI NG CONTRI BUTI ON

h 4 ~ ~Fo r m VE RI F I E D STATEMENT

REGI STRATI ON( O u t - o f - S t a t e Co mmi t t e e s )

( Re v 0 3 / 0 5 )Fo r o f f i c e u s e o n l yComm #I n d e x e dAu d i t e dC h e c k e dCo mp u t e r

PARENT ENTI TY, AFFI L I ATE, SPONSOROF COMMI TT EE( Us e s ep a r a t e p a g e i f n e e d e d t o l i s t mo r e t h a n one e n t i t y )

T y p e d Name o f I o w a Re si d en tMr s . De b o r a h Gr o e n e7 2 3 3 6 t h S t r e e t Ma i l i n g Ad d r e s s

C i t y , S t a t e , Z i p C o d e Ar e a C o d e &T el e p ho n e No .De s Mo i n e s , I A 5 0 3 1 2 ( 5 1 5 ) 2 8 9 - 0 4 8 2

Name o f Co mmi t t e eJ e a n e t t e Wo o d s f o r S c h o o l Bo a r d

Ma i l i n g Ad d r e s s4 3 2 0 N. W. 2 n d A v e n u e De s Mo i n e s , I A 5 0 3 1 3Da t e0 8 / 1 7 / 2 0 0 5

Amou n t$ 5 0 0 . 0 0

I f I n - K i n d C o n t r i b u t i o n , De sc r i b e

C h e c k #3 0 3 3 Co mmi t t e e . I D #

I Co e6 ( r CA " L 1 S , a t t e s t t h a t t h e c on t r i b ut i o n r e p o r t e d above i s a c c ur a t e and t h a t t h e i n f o r ma t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t e e i s c o r r e c t an d a c c ur a t e t o t h e b e s t o f my k n o w l e d g e . 1 a l s o a t t e s t t h a t t h e r e p o r t s f i l e d i n t h e na med j u r i s d i c t i o n c o mp l y wi t h r e qu i r e me n t s t h a t a r esubs t an t i a l l y s i mi l a r t o I o wa Code s ec t i o n 6 8 A 4 0 2 A 6 , i n c l ud i n g t h e d i s c l o su r e o f a l l c on t r i b ut i o ns r e c e i v e d and a l l e x p en d i t u r e s made . 1 f u r t h e r a t t e s t t h a t t h ec on t r i b ut i o n r e p o r t e d a b o v e was made f r o m a n a cc ou n t t h a t d o e s n o t a c c e p t c o nt r i b ut i o ns f r o m c o r p o r a t i o ns o r o t h e r p r o h i b i t e d c on t r i b ut o r s u n d e r I o wa Codes ec t i o n 68 A . 5 0 3 , u n l e s s t h e I o wa r e c i p i e nt c o mmi t t e e i s a b al l o t i s s ue c o mmi t t e e . I u nd e r s t a n d t h a t p o t e n t i a l c i v i l an d c r i mi n a l p en a l t i e s may a p p l y u n l e s s a c o pyo f t h i s f o o v 4 as b e e n f i l e d wi t h t h e I o wa Et h i c s and Campa i gn Di s c l o s u r e Bo a r d wi t h i n 1 5 d a y s o f t h e d a t e o f t h e c on t r i b ut i o n .7 R' e 7 + SUk 6 -e_ 2~ - U5( Pe r s o n s u b mi t t i n g f o r m) ( T i t l e ) ( D a t e )

S a n d r a B r o o k sName1 7 5 0 Now Y * r k A v e n u e , NW Wa s h i n g t o n , DC 2 0 0 0 6Ma i l i n g Ad d r e s sS B r o o k s ( a- , ) i u p a t . o r g C i t y , S t a t e , Z i p( 2 0 2 ) 6 3 7 - 0 7 7 2E ma i l Ad d r e s s ( O p t i o n a l ) Ar e a C o d e & T el e p h o n e Numbe r


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I OWA ETHI CS ANDCAMPAI GN DI SCLOSURE BOARD5 1 0 EAST 1 2 t h , SUI TE 1A' I . DES MOI NES, I A 5 0 3 1 9www. l o wa . g o v / e t h i c sVERI FI EDSTATEMENTREGISTRATION

COMMI TTEE NAME

CONTACT PERSON FOR THE COMMI TTEE :

I OWA RESI DENT AGENT

( P e r s o n s w b m i t t i n g f o r m )

( O u t - o f - S t a t e Co mmi t t e e )

Pu r p o s e o f C o mm i t t e e / C o n t r i b u t i o n : ( P l e as e i n d i c a t e b y c h ec k i n g a pp r o pr i a t e b o x )

STATE OR FEDERAL JURI SDI CT I ON WHERE COMMI TTEEI S REGI STEREDOR OPERATES

VERI F I ED STATEMENT OF COMMI TTEE :

COMMI TT EES NOT ORGANI ZED I N I OWA TO COMPLETE I N DUPL I CATE .SEND A COPY TO THE BOARDWI THI N 1 5 DAYS OF THE CONTRI BUTI ON DATE ANDONE COPY WI TH EACH CONTRI BUTI ON TO THE I OWA COMMI TT EE WI TH THE CONTRI BUTI ONPLEASE REFER TO DETAI LED I NSTRUCTI ONS ON BACK OF FORM.THI S FORMMUST BE F I LED FOR EACH CONTRI BUTI ON I N EXCESS OF $ 50

O f f i c i a l Name o f O u t - o f - S t a t e Commi t t e e ( D o n o t a b b r e v i a t e c o mm i t t e e name . Wr i t t e n e x p l a n a t i o n mu s t b e p r o v i d e d f o r A c r o n y m) .T n t e r n a t i o n a l TTn i n n o f Pa i n t e r c &A l l i e d Tr a d e s P o l i t i c a l A c t i o n Commi t t e e1 7 5 0 New Y o r k A v e n u e , NW M a i l i n g A d dr e s s

C i t y , S t a t e , Z i p CodeWa s h i n g t o n , DC 2000 6 A r e a Code & T e l e p h o ne No .( 2 0 2 ) 6 3 7 - 0 7 0 0

OCa n d i d a t e El B a l l o t I s s ue PAC Ot h e r PAC 1 : 1 Pa r t y ( S t a t e o r Ce n t r a l Co mmi t t e e )

Fo r m VERI F I ED STATEMENTREGI STRATI ON( O u t - o f - S t a t e C o mm i t t e e s )( Re v . 0 3 / 0 5 )

F o r o f f i c e u s e o n l yComm . #I n d e x e dA u d i t e dChe c k e dCompu t e r

PARENT ENT I T Y, AF FI L I AT E, SPONSOR OF COMMI TTEE( U s e s e p a r a t e p a g e i f n e e d e d t o l i s t mo r e t h a n o n e e n t i t y )Name o f J u r i s d i c t i o n

F e d e r a l F l e c t i o n Commi s s i o nM a i l i n g A d d r e s s9 9 9 E S t r e e t , NWC i t S t a t e , Z i p Code A r e a Code & T e l e p h o n e NoWsh i n i t o n , DC ( 2 0 2 ) 6 9 4 - 1 1 0 0

NameI n t e r n a t i o n a l Un i o n o f P a i n t e r s & A l l i e d T r a d e s1 7 5 0 New Yo r k A v e n u e ,Wss

C i t S t a t e , Z i p CodeWa s h i n g t o n . DC 2 0 0 6I OWA COMMI TTEE RECEI VI NG CONTRI BUTI ON

T y p e d Name o f I o w a R e s i d e n tMr s . De bo r a h Gr o e n e7 2 3 3 6 t h S t r e e t

M a i l i n g A dd r e s s

C i t y , S t a t e , Z i p Code A r e a Code & T e l e p h on e No .Des M o i n e s , I A 50312 ( 5 1 5 ) 2 8 9 - 0 4 8 2

Name o f Commi t t e eJ o e Mo r r f o r S c h o o l Bo a r dM a i l i n g A d d r e s s4 09 S .W. Wa l n u t S t r e e t An k n e y , I A 5 0 0 2 3

Da t e0 8 / 1 7 / 2 0 0 5Amount$ 5 0 0 . 0 0

I f I n - K i n d C o n t r i b u t i o n , D e s c r i b e

Check #3 0 3 4 Co mmi t t e e . I D #

I E) E ck6,E C- 7 x } - - L i - S , a t t e s t t h a t t h e c o n t r i b u t i o n r e p o r t e d a b o v e i s a c c u r a t e a n d t h a t t h e i n f o r m a t i o n a b o u t t h i s o u t - o f - s t a t ec o mmi t t e e i s c o r r e c t a n d a c c u r a t e t o t h e b es t o f my k n o wl e d ge I a l s o a t t e s t t h a t t h e r e p o r t s f i l e d i n t h e na med j u r i s d i c t i o n c o mp l y w i t h r e q u i r e me n t s t h a t a r es u b s t a n t i a l l y s i m i l a r t o I o wa Code s e c t i o n 6 8A402A6 , i n c l u d i n g t h e d i s c l o s u r e o f a l l c o n t r i b u t i o n s r e c e i v e d a n d a l l e x p e n d i t u r e s m a d e . I f u r t h e r a t t e s t t h a t t h ec o n t r i b u t i o n r e p o r t e d a b o v e wa s made f r o m a n a c c o u n t t h a t d o e s n o t a c c e pt c o n t r i b u t i o n s f r o m c o r p o r a t i o n s o r o t h e r p r o h i b i t e d c o n t r i b u t o r s u n de r I o w a Codes e c t i o n 6 8 A . 5 0 3 , u n l e s s t h e I o wa r e c i p i e n t c o mmi t t e e i s a b a l l o t i s s u e c o mmi t t e e . I u n d er s t a n d t h a t p o t e n t i a l c i v i l a n d c r i m i n a l p e n a l t i e s may a p p l y u n l e s s a c o p yo f t h i s f o r m h a s be en f i l e d w i t h t h e I o wa E t h i c s a n d Camp a i g n D i s c l o s u r e Bo a r d w i t h i n 1 5 d a y s o f t h e d a t e o f t h e c o n t r i b u t i o n .2 EA- Su 1 2 2 g , - 2 ~ - D5

( T i t l e ) ( D a t e )

S a n d r a B r o o k sName1 7 5 0 Ncw Yo r k A v e n u e , NW Wa s h i n g t o n , DC 2000 6M a i l i n g A d dr e s sS B r o o k s ( & i u p a t . o r g C i t y , S t a t e , Z i p( 2 0 2 ) 6 3 7 - 0 7 7 2E ma i l A d d r e s s ( O p t i o n a l ) A r e a Code & T e l e p h o ne Number


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