Jacobsen Connie__1683__scanned

download Jacobsen Connie__1683__scanned

of 4

Transcript of Jacobsen Connie__1683__scanned

  • 8/7/2019 Jacobsen Connie__1683__scanned

    1/4

    FOR I NSTRUCTI ONS, SEE BACK OF FORMDI SCLOSURE SUMMARY PAGECOMMI TT EE NAME( Mus t b e same a s o n S t a t e me n t o f O r g a n i z a t i o n )

    I MPORTANT : I n d i c * 6 b y # t y p e o f c o mmi t t e e y o u a r e r e p o r ) ( n g f o r :( 1 ) S t a t e w i d e / L e g i s l a t i v e / J u d g e S t a n d i n g f o r R e t e n t i o n C a n d i d a t e ( 2 ) S t a t e PA C ( 3 ) S t a t e P a r t y( 4 ) C o u n t y C e n t r a l C o mmi t t e e ( 5 ) C o u n t y C a n d i d a t e ( 6 ) C i t y C a n d i d a t e ( 7 ) S c h o o l B o a r d o r O t h e rP o l i t i c a l S u b d i v i s i o n C a n d i d a t e ( 8 ) C o u n t y PAC ( 9 ) C i t y PAC ( 1 0 ) S c h o o l B o a r d o r O t h e r P o l i t i c a lS u b d i v i s i o n PAC ( 1 1 ) L o c a l B a l l o t I s s u eCANDI DATE COMMI TT EES ONL Y :C a n d i d a t e Name

    Fyi, F e l i t i c a 1 ; R H t t y ( i f a p p l i c a b l e )

    O f f i c e S o u g h t 3 z ~ 0 0 [ r i t t ( i f S b n a t e o r H o u s e )f Vn I 1 _z , 0, ~ ~ 1 3 03L a t e r e p o r t s a r e s u b j e c t t o p o s s i b l e c i v i l a n d c r i mi MV p e n a k i e s . . WS n a n t 4 - l o t y a . o d e s e c t i o n 6 8 B . 3 2 A ( 7 )t h e c a n d i d a t e , f o r a c a n d i d a t e ' s c o mmi t t e e , a n d t h e c h a i r p e r s o n , f o r a n y o o f c o mmi t t e e , i s t h ei n d i v i d u a l r e s p o n s i b l e f o r f i l i n g t i me l y a n d a c c u r a t e r e p o r t s .

    9 0 7 7SI GNATURE OF PERSON F I L I N G R E P ,

    I AM F I L I N G A I V0 4 J N l( r e p o r t d a t e )

    - , I ECK I F AMENDMENT TO REPORT DATEDChe c k i f t h i s i s f i n a l ( t e r mi n a t i o n ) r e p o r t a n d a t t a c h N o t i c e o f D i s s o l u t i o n Fo r m DR- 3 .( Y o u must c o n t i n u e t o f i l e r e p o r t s u n t i l a DR- 3 i s f i l e d . )

    CASH ON HAND a t t h e b e g i n n i n g o f t h e r e p o r t i n g p e r i o d . ( T o t a l o f a l l f u n d s h e l d b y t h ec o mmi t t e e . T h i s a m o u n t MUST b e t h e same a s t h e c a s h o n h a n d a t t h e e n do f t h e l a s t r e p o r t i n g p e r i o d o r must b e z e r o i f t h i s i s f i r s t r e p o r t f i l e d . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ADD TOTAL MONEY TAKEN I N THI S PERI ODS c h e d u l e A : Cash C o n t r i b u t i o n s t o t a l ( A t t a c h S c h e d u l e A ) ( * a l s o s e e i n - k i n d b e l o w ) . . . . . . . . . . . . . . . . . . . . . . .S c h e d u l e F : L o a n s R e c e i v e d t o t a l ( A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S c h e d u l e H : T o t a l S a l e s o f Camp a i g n P r o p e r t y ( A t t a c h S c h e d u l e H ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    ( Sc h e d ul e a v l i e s t o Ca n d i d a t e s ' Co mmi t t e e s On l y )

    SUBTRACT TOTAL MONEY SPENT THI S PERI OD

    R e s e t F o r m

    STATEMENT OF CASH ON HA ND

    FORMDR- 2 DI SCLOSURE( Re v . 1 2 / 2 0 0 5 ) REPORTF o r O f f i c e Us e O n l yCo mm . # 160L o g g e d I n `S c a n n e dCompu t e rA u d i t e d

    F i l e w i t h :I o wa E t h i c s a n d Campa i g nD i s c l o s u r e B o a r d5 1 0 E . 1 2 " ' , S t e . 1 ADes Mo i n e s , I o w a 5 0 3 1 9F a x : 5 1 5 - 2 8 1 - 3 7 0 1

    y_ 3 1 q - 4 Y 4 , 111A14

  • 8/7/2019 Jacobsen Connie__1683__scanned

    2/4

    Fo r I n s t r u c t i o n s , Se e B a c k o f Fo r mCONTRI BUTI ONS - - MONEYTAKEN I N

    ( I n c l u d i n g c a n d i d a t e ' s p e r s o n a l f u n d s )COMMI TTEE NAME ( Mu s t b e s ame a s o n S t a t e me n t o f O r g a n i z a t i o n )

    R e s e t F o r m SCHEDUL EA MONETARY( Re v . 0 7 / 0 3 ) RECEI PTS0CHECK THI S BOX I FAMENDI NG FORM

    STATE CANDI DATES A I T E : I F A CONTRI BUTI ON I S RE E I V E D FROM A S TA TE PAC ( P OL I T I C A L AC T I ON C OMMI T T E E ) , L I S T THE PAC I D EN T I F I C A T I O NNUMBER AND T HE P AC CHECK NUMBER I N THE DESI GNATED COL UMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM T HE I OWA E T HI C S AND CAMPAI GNDI SCLOSURE BOARD .NOTE : ANY PERSON, OTHERTHAN AN I N DI V I D U A L , THAT CONTRI BUTES MORE THAN $ 7 5 0 TO YOUR CAMPAI GN MAY HAVE F I L I N GRESPONSI B I L I T I ES AND SHOULD I MMEDI ATELY CONTACT THE BOARD .CAUT I ON : S e c t i o n 6 8 B . 3 2 A ( 6 ) , p r o h i b i t s t h e u s e o f i n f o r ma t i o n c o p i e d f r o m r e p o r t s an d s t a t e m e n t s f o r s o l i c i t i n g c o n t r i b u t i o n s o r f o r a n yc omme r c i a l p ur p o s e b y a ny p e r s o n o t h e r t h a n s t a t u t o r y p o l i t i c a l c o mmi t t e e s .

    SUB- TOTAL -g 3 C 4 : ~ t S , VCTOTAL ( i f l a s t p a g e o f t h i s s c h e du l e )

    D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e c o mm i t t e e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e m a k i n g a c o n t r i b u t i o n t o t h ec o mm i t t e e . R e l a t i o n s h i p m u s t b e s h o wn t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f t y ( r e l a t i v e s b yma r r i a g e ) . I f s u r n ame o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n o Page-~o f1f a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn . ( f o r S c h e d u l e A )

    DATE PAC I D NUMBER NAME AND ADDRESS F CONTRI BUTOR RELAT I ONSH I P AMOUNT J I F FORRECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE* RECEI VED FUND-( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SERNUMBER I NCOME

    CK#~~' ~~ u c - _ _ SuZA/ Gbl SOLDf ~ ' Y aI D# 04, 4 4s ' 9 1 l a I V C, w z s a 3 3 -I D# Ck ~, 1 4 4 CAi G/ . i ~. ~/ 1 3 e - - Z~ L q

    I D# ,CK# / d fI D#C K#

    C K#I D#C K#I D#C K#

    I D#CK#I D#C K#

  • 8/7/2019 Jacobsen Connie__1683__scanned

    3/4

    T HI S BOX APPL I E S TO CANDI DATES ' COMMI TTEES ONLY :P u r c h a s e s o f c e r t a i n c a mp a i g n p r o p e r t y c o s t i n g $ 5 0 0 o r mo r e mu s t a l s o b e i n v e n t o r i e d o n S c h e d u l e H . ( R e f e r t o S c h e d u l e H i n s t r u c t i o n s . )E x p e n d i t u r e s t o p e r s o n s / e n t i t i e s p r o v i d i n g c o n s u l t i n g , a d v e r t i s i n g , f u n d - r a i s i n g , p o l l i n g , ma n a g i n g , o r g a n i z i n g s e r v i c e s mu s t a l s o b e d e t a i l i t e m i z e d o nS c h e d u l e G b y t h e a mo u n t , p u r p o s e , a n d d a t e o f e a c h t y p e o f e x pe n d i t u r e made b y t h e p e r s o n / e n t i t y o n b e h a l f o f t h e c a n d i d a t e ' s c o mmi t t e e . ( R e f e r t oS c h e d u l e G i n s t r u c t i o n s a n d I o w a Code 6 8 A . 4 0 2 ( 3 ) ( i ) . )

    ( f o r S c h e d u l e B )

    / - U K I I V J I KUC: I I ONS, SEE BACK OF FORM I K e s e t c o r m / SCHEDULEEXPENDI T URES - - MONEY SPENT FROM COMMI T T EE ACCOUNT B MONETARY( R e v . 0 7 / 0 3 ) EXPENDI TURESS TA TE PAC COMMI TT EES : NOTE : FOR CONTRI BUTI ONS MADE T O S T AT EWI DE OR LEGI SLAT I VECANDI DATES, L I S T T HE CANDI DATE I D E NT I F I C A T I O N NUMBER I N T HE DESI GNATED COLUMN AND T HE DCHECK T HI S BOX I FPAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM T HE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD .

    COMMI TTEE NAME ( M u s t b e same a s o n S t a t e me n t o f Or g a n i z a t i o n )

    CAN? AT E NAME AND ADDRESS WHOM PURPOSE AMOUNTDATE I D Nt 7MBER EXPENDI TUR ( DESCRI BE TRANSACT I ON) EXPENDEDEXPENDED ( i f a p p l i c a b l e ) ( D i s b u r s e me n t ) WAS MADE( MM/ DD/ YR) AND PACCHECKNUMBERD# R Aj / p v

    CK# l 6 / d S a o > 4~dt ysLa. Y dG~ ' + +~ - r ~ ~ ~~l ~ODD"Z I o St%Q6 D# 6 ~ w,CK# 1 0 ) 1 976 . 0 0D# 0 .0 PRP ,CK# / Ol a 7 , 9I D # S ' & S , I - 3D~ o CK# ~ 0 i . 3 e s ' f ~ p . ~ i c hI D # /CK#D#CK#D#CK#

    SUB- TOTAL $ 4&7 , 4 9TOTAL ( i f l a s t p a g e o f t h i s s c h e d u l e ) $

  • 8/7/2019 Jacobsen Connie__1683__scanned

    4/4

    FOR I NSTRUCT I ONS, SEE BACK OF FORMCOMMI TT EE NAME ( M u s t b e s ame a s o n S t a t e m e n t o f O r g a n i z a t i o n )

    SCHEDULEE I N- K I ND( R e v . 0 6 / 9 7 ) 1 CONTRI BUT I ONSCHECK T H I S BOX I FAMENDI NG FORM

    TOTAL ( i f l a s tp a g e o f t h i s

    s c h e d u l e )* D i s c l o s u r e l a w r e q u i r e s c a n d i d a t e s t o d i s c l o s e t h e r e l a t i o n s h i p o f a n y r e l a t i v e ma k i n g a n i n k i n d c o n t r i b u t i o n t o t h e P a g e-Lo fc o mm i t t e e . R e l a t i o n s h i p mu s t b e s h o w n t o t h e t h i r d d e g r e e o f c o n s a n g u i n i t y ( b l o o d r e l a t i v e s ) a n d a f f i n i t y ( r e l a t i v e s ( f o r S c h e d u l e E )b y m a r r i a g e ) . ( S e e P a g e 2 o f f o r m s p a c k e t . ) I f s u r n a me o f c o n t r i b u t o r i s t h e s ame a s c a n d i d a t e , b u t t h e r e i s n of a m i l i a l r e l a t i o n s h i p , e n t e r " n o t a p p l i c a b l e " i n t h e r e l a t i o n s h i p c o l u mn .

    DATERECEI VED( MM/ DD/ YR) NAME AND ADDRESSOF CONT RI B UT ORRELAT I ONSHI PT O CANDI DATE* ( i f a p p l i c a b l e )

    DESCRI PT I ONOF I N K I NDCONTRI BUT I ONEST I MATEDF AI R MARKETVALUE

    J I F FORFUND- RA I SERCONTRI BUT I ON2 PZ~. 3 a 9

    I I Q C ' Cl - Ma y l $

    c , r l. . . . . . J

    RP1- , ,

    . 9 4 1s I S 7. 2 . , o f E : 1/ 0 l 8 f ~P~F

    t v , / , ~ ~o b P * ~ " - ' V 4 d s / " 7 4 ' 0 , &0 Fo~. t l b 4 RaS 9 4 - k u I l e3 o 5 Ap c r c A e DQ

    k p i l e u . ) a : e , Z S~ 1 - 3 1 St ~~ ~ - 1 1 7 , 00 E : 1

    F - 1