employers mutual casualty co pac6033scanned

8/7/2019 Employers Mutual Casualty Co PAC__6033__scanned

http://slidepdf.com/reader/full/employers-mutual-casualty-co-pac6033scanned 1/8

/ 1 8/ 2 00 4 08 : 3 9 FAX 5 1 5 2 8 0 2 7 5 4 EMC I NSURANCE EXECUTI VE

FOR I NSTRUCTI ONS, SEE BACK OF FORM

DI SCLOSURE SUMMARY PAGE

COMMI TTEE NAME ( M u s 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 )

E mp l o y e r s Mu t u a l C a s u a l t y Co P o l i t i c a l A c t i o n Comm f o r R e s p o n s i b l e S t a t e G o v t

I MPORTANT : I n d i c a t e 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 t i n g f o r : F 2 J( 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 PAC ( 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 ( 10 ) Sc h o o l B o a r d o r O t h e r P o l i t i c a l

S 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 e

HECK I F AMENDMENT TO R

( Y o u mu s t 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 . )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 .

REPORT FOR ( 1 ) ELECTI ON / ( 2 ) NON- ELECT I ON YEAR .I n d i c a t e b y #

STATEMENT OF CASH ON HAND

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 e

c o mmi t t e e . T h i s amoun t MUST b e t h e same a s t h e c a s h o n h a n da t

t h e e n do f t h e l a s t r e p o r t l n g p e r i o d o r mu s t 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2 , 1 9 3 . 8 2

ADD TOTAL MONEYTAKEN I N THI S PERI OD

S 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 ) . . . . . . . . . . 1 , 6 3 4 . 5 0

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 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

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 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

( S c h e d u l e H a p p l i e s t o C a n d i d a t e s ' Commi t t e e s O n l y )

SUB- TOTAL . . . . . $ 3 , 828 . 3 2

SUBTRACT TOTAL MONEY SPENT THI S PERI OD

S c h e d u l e B : E x p e n d i t u r e s t o t a l ( A t t a c h S c h e d u l e S ) ( * * a l s o s e e d e b t s a n d l o a n s b e l o w ) . . . . 550 . 0 0

S c h e d u l e F : L o a n Re p a y me n t s t o t a l ( A t t a c h S c h e d u l e F ) . . , . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

CASH ON HAND a t t h e e n d o f t h i s r e p o r t i n g p e r l o d ( i f f i n a l r e p o r t b a l a n c e mu s t 3 , 2 7 8 . 3 2b e z e r o ) ( A t t a c h DR- 3 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

" UNP AI D BI L L S ( F r o m S c h e d u l e D - A t t a c h S c h e d u l e D ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

* I N KI ND CONTRI BUTI ONS ( F r o m S c h e d u l e E - A t t a c h S c h e d u l e E ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

* * OUTSTAND I NG LOANS ( F r o m S c h e d u l e F - A t t a c h S c h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

CANDI DATECOMMI TTEES ONLY:

CONSUL TANT BREAKDOWN ( S c h e d u l e GA t t a c h e d ? )

VALUE OF CAMPAI GN PROPERTY ( F r o m S c h e d u l e H - A t t a c h S c h e d u l e H ) $

FORM

DR- 2 DI SCLOSURE

( R e v . 0 7 / 2 0 0 4 ) REPORT

F o r O f f l e e UseO n l y

Comm #

L o g g e d I n

S c a n n e d

C o mp u t e r

A u d i t e d

L o c a l C o mmi t t e e s , e n t e r D a t e o f E l e c t i o n

C o u n t y & L o c a l C o mmi t t e e s , e n t e r C o u n t y I nw h i c h E l e c t i o n i s h e l d

0

0

0

/ D - / , h - o ' y

DATE SI GNED

YES

0 0 3

CANDI DATE COMMI TTEES ONLY:

C a n d i d a t e Name P o l i t i c a l P a r t y ( i f a p p l i c a b l e )L 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 n a l

O f f i c e S o u g h t D i s t r i c t ( i f S e n a t e o r H o u s e ) p e n a l t i e s .



/ 1 8/ 2 00 4 08 : 3 9 FAX 5 1 5 2 8 0 2 7 5 4 EMC I NSURANCE EXECUTI VE Z0 0 4

Fo r I n s t r u c t i o n s , Se e Ba c k o f Fo r m

CONTRI BUTI ONS - - MONEY TAKEN 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 St a t eme n t o f O r g a n i z a t i o n )

Emp l o y e r s Mu t u a l Ca s u al t y Co . P o l i t i c a l Ac t i o n Com. f o r Re s p on s i b l e S t a t e Gov t

STATECANDI DATES NOTE : I F ACONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THEPAC I DENT I F I CATI ONNUMBERAND THEPAC CHECK NUMBER I N THE DESI GNATED COLUMN. A L I S T OF I D NUMBERS I S AVA I LABLEFROMTHE I OWA ETHI CS AND CAMPAI GN

DI SCLOSURE BOARD.

CAUTI ON : S e c t i o n 6 8B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r m a 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 an y c o mme r c i a l p u r 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 es .

SUB- TOTAL

TOTAL ( i f l a s t p a g e o f t h i s s c h ed 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 c o m m 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 ma 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 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 b y 1 6m a 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 f - _f 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 )

SCHEDULE

A MONETARY

( Re v 0 7 / 0 3 ) RECEI PTS

QCHECKTHI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT q I F FOR

RECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-( MMI DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SER

NUMBER I NCOME

7 / 27/ 36, 8/ 1

7 / ] _ { I D#Ron He r man

$ 1 7 . 5 08/ 2 7, 9 / 10

,PK# 1 2 0 9 Benwoo d C t

9 / 2 4 / 0 4 A l t o o n a , I A 7 x $ 2 . 5 0 =

I D#Gr e g C h r i s t i a n s o n

I t

CK# 7819 Hwy 5 5 2 N 2 2 . 7 5B a x t e r , I A 5 0 0 2 8 7 x $ 3 . 2 5 =

I D#He at h er Bo u s t e ad

CK# 7 6 1 8 Ma d i s o n Av e 2 4 . 5 0

De s Mo i n es I A 7 x $ 3 . 5 0 =

I D#J ames Daws on

CK# 9 0 1 7 Ri d ge v i e wDr1 7 . 5 0

J o h n s t o n , I A 5 0 1 3 1 7 x $ 2 . 5 0 =I D#

Da v i d Gr z o s k o wi a

" CK# 4400 P a r k Av e . , # 1 61 7 . 5 0

De s Mo i n e s , I A 5 0 3 2 1 7 x $ 2 , 5 0 =

I D#Ma r t i n Reed

CK# 7 3 7 E Wa l n u t , # 29 2 8 . 0 0E l k h a r t , I A 5 0 0 7 3 7 x $ 4 . 0 0 =

I D#Adam Ro u r k e

CK# 3 8 6 2 1 5 t h Av e1 7 . 5 0

H a r t f o r d , I A 50118 7 x $ 2 . 5 0 =

I D#De n i s e Me r n k a

CK# 4 3 2 8 New Y or k Av e1 4 . 0 0

De s Mo i n e s , I A 50310 7 x $ 2 . 0 0 =

I D#Mi k e Ha n ba c k

CK# 4 2 1 2 Adams2 2 . 7 5

De MMonnes I A 50 31 0 7 x $ 3 . 2 5 =I D#

J o e Smi t h

~ CK# 6 8 8 5 Sh a r o n Dr 3 5 , 0 0Ur b a n d al e , l A 5 0 3 2 2 7 x $ 5 . 0 0 =



/ 1 8 / 2 00 4 0 8 : 4 0 FAX 5 1 5 2 8 0 2 7 5 4 E 3 1 C I NSURANCE EXECUTI VE 2005

Fo r I n s t r u c t i o n s , Se e Bac k o f Fo r m



COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t e me n t o f Or g an i z a t i o n)

Emp l o y e r s Mu t u a l C a s u a l t y Co . P o l i t i c a l A c t i o n Comm. f o r R e s p o n s i b l e S t a t e Go v

SCHEDULE

A MONETARY

( Re v . 0 7 / 0 3 )

IRECEI PTS

QCHECKTHI S BOX I F

AMENDI NGFORM

STATECANDI DATES NOTE: I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE ) , L I S T THEPAC I DENTI F I CATI ONNUMBER ANDTHEPAC CHECK NUMBER I N THEDESI GNATED COLUMN. A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA ETHI CS ANDCAMPAI GN

DI SCLOSURE BOARD.

CAUTI ON : S e c t i o n 6 8B . 3 2 A ( 6 ) , I o wa Cod e , 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 op i e d f r om r e p o r t s an d s t a t e me nt 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 ns o r

f o r an y c omme r c i a l p u r p o s e b y a n y p e r s o n o t h e r t h an 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 I $ 3 0 7 . 4 4

TOTAL ( 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 di d a t e c ommi 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 ny r e l a t i v e mak i n g a c o n t r i b u t i o n t o t h ec ommi t t e e . R e l a t i o n s h i p mus 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 ) and a f f i n i t y ( r e l a t i v e s b y 2 6ma r r i a g e ) 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 same a s c a n d i d a t e , b ut t h e r e i s no Page o f -

f a mi 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 Sc h e du l e A)

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT 4 I F FOR

RECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE` RECEI VED FUND-

( MM/ DD/ YR) AND PACCHECK ( i f a p p l i c a b l e ) RAI SER

NUMBER I NCOME

7 67 /7/ 2

3b , 8/

I ~ ,

I D#Ke n Cump s t o n

$17 . 5 08/ 27 : 9 / 1 , CK#

1 9 0 0 NW152nd S t

9 / 2 47 04 C l i v e , I A 5 0 3 25 7 x $ 2 . 5 0 - -I D#

Dave Hi x e n b a u g h1 1 CK# 4 9 0 3 La k ewo o d Dr 2 2 ' 7 5

N o r w a l k , I A 5 0 2 1 1 7 x $ 3 . 2 5 =

I D #

Mi k e Bl o o mb u r g

CK# 4 6 3 8 El m1 0 . 5 0

We s t Des Mo i n e s I A 5 0 2 6 5 7 x $ 1 . 5 0 =

I D#Ro n H a l l e n b e c k

CK# 5 8 8 0 Br e n t wo o d2 8 . 0 0

J o h n s t o n , I A 7 x $ 4 . 0 0 =

I D#Doug Nu e h r i n g

CK# 1 4 4 3 0 B r y n Mawr1 4 , 0 0

LjU r b a n d a l e , I A 5 0 3 2 3 7 x $ 2 . 0 0 =

I D#Cu r b s Hu s s k e

CK# 3 00 Ba l d wi n S t 1 3 . 4 4" Ma x w e l l , I A 5 0 1 6 1 7 x $ 1 . 9 2 =

I D#Ni c k K o l a c i a

CK# 8 8 1 7 Hi c k man Rd . , Ap t 70 47 0 . 0 0

U r b a n d a l e , I A 5 0 3 2 2 7 x $10 . 0 0=

I D#J o h n Power

CK# 217 El m Av e 3 5 . 0 0

S t o r y C i t y , I A 7 x $ 5 . 0 0

I D#Ge o r g i a Rhoades

CK# 3 6 3 3 C o r n e l l 7 0 . 0 0

De s Mo i n e s I A 5 0 3 1 3 7 x $ 1 0 . 0 0 =

I 'I D#

Na t h a n Habben

CK# 210 S P r a i r i e Vi e w Dr . , Ap t 8 3 7 2 6 . 2 5

Wes t Des Mo i n e s , I A 7 x $ 3 . 7 5 =



/ 1 8/ 2 00 4 08 : 4 0 FAX 5 1 5 2 8 0 2 7 5 4 EMC I NSURANCE EXECUTI VE 0006

Fo r I n s t r u c t i o n s , Se e Ba c k o f Fo r m



COMMI TT EE NAME ( Mu s t b e s ame a s o n St a t eme n t o f O r g a n i z a t i o n )

Emp l o y e r s Mu t u a l Ca s u a l t y Co . P o l i t i c a l Ac t i o n Comp . f o r Re s po ns i b l e S t a t e Gov

TOTAL ( i f l a s t page o f t h i s s c h ed u l e )

STATE CANDI DATES NOTE ; I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C AL ACT 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 THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN . A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA E T HI C S AND CAMPAI GNDI SCLOSURE BOARD .

CAUTI ON : S e c t i o n 6 8 B , 3 2 A ( 6 ) , I o wa C o d e , p r o h i b i t s t h e u s e o f I n f o r m a t i o n c o p i e d f r o m r e p o r t s a n 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 an y c omme r c i a l p u r p o s e b y an y 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 ommi t t e es .

SUB- TOTAL $ 2 8 8, 1 9

` 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 e

c 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 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 b y 3 6m a r r i a g e ) . I f s u r name 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 a n o Pa g e _of -

f 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 )

SCHEDULE

A MONETARY

( R e v . 0 7 / 0 3 ) RECEI PTS

QCHECK T HI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAMEAND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT q I F FOR

RECEI VED ( i f a p p l i c a b l e ) TO CANDI DATE' RECEI VED FUND-

( MM/ DDI YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SER

NUMBER I NCOME

'3 6

b I D#Mi k e F r e e l

$ 2 2' 7 5/ 2 7 , 9 / 1 0 , CK # 4 2 1 3 E Eu c l i d

1 24 / 0 4 De s Mo i n e s , I A 7 x $ 3, 2 5 =

I D#IBob Mo r l a n

CK# 3 4 0 4 Wa k o n d a Ct 107 . 6 6

De s Mo i n e s , I A 5 0 3 2 1 7 x $ 15 . 3 8 =

I D#Mo n t e Ba l l

CK# 3 04 4 1s t S t 3 5 . 0 0

De s Mo i n e s , I A 7 x $ 5 . 0 0 =

1D#Ma r k Mc Co l l e y

CK# 8 901 Bo s t o n Av e2 2 . 4 0

Ur b a n d al e , I A 5 0 3 2 2 7 x $ 3 . 2 0 =

I D#He r b S u f f e l

CK# 9 9 0 3 r d2 6 . 2 5

Waukee , I A 5 0 2 6 3 7 x $ 3 . 7 5 =

I D#Ro b F r i e dma n

CK#9 3 9 0 L a k ew o o d C i r c l e 2 6 . 8 8

No r wa l k , I A 50211 7 x $ 3 . 8 4 =

I D#Ca r o l Ha l l e n b ec k

CK# 5 8 8 0 Br e n t wo o d1 4 . 0 0

J o h n s t o n , I A 7 x $ 2 . 0 0 =

I D#Be e c h Tumer

CK# 1 9 0 4 7 5 t h S t1 7 . 5 0

De s Mo i n e s , I A 5 0 3 2 2 7 x $ 2 . 5 0

I D#Sh a r o n Ge n t s c h

CK# 4 0 8 L a c o n a8 . 7 5

De s Mo i n es l A 5 0 3 1 5 7 x $ 1 . 2 5 =

I D#L e a n n Goebe l

CK# 2 6 0 8 6 8t h S t 7 . 0 0

Ur b a n d al e , I A 5 0 3 2 2 7 x $ 1 . 0 0=



/ 1 8/ 2 00 4 08 : 4 0 FAX 5 1 5 2 8 0 2 7 5 4 EMC I NSURANCE EXECUTI VE 0 0 0 7

Fo r I n s t r u c t i o n s , Se e B a c k o f Fo r m

CONTRI BUTI ONS - - MONEY TAKEN 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 ( M u s t b e same a s o n St a t eme n t o f O r g a n i z a t i o n )

Emp l o y e r s Mu t u a l C a s u a l t y Co . P o l i t i c a l A c t i o n Comm. f o r R e s p o n s i b l e S t a t e Go v

STATE CANDI DATES NOTE: I F ACONTRI BUTI ON I S RECEI VED FROMASTATEPAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I DENT I F I CATI ONNUMBER ANDTHE PACCHECKNUMBER I N THE DES I GNATED COLUMN . A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA ETHI CS AND CAMPAI GN

DI SCLOSURE BOARD .

CAUTI ON : S e c t i o n 68B . 3 2 A ( 6 ) , I o w a C o d e , p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n 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 y c o m me r c i a l p u r p o s e b y a n y 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 mm i t t e e s .

SUB- TOTAL


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 m m 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 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 b y 4 6m a r r i a g e ) . I f s u r n a m e o f c o n t r i b u t o r i s t h e s am e a s c a n d i d a t e , b u t t h e r e i s n o P a g e -__- o f-f 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)

SCHEDULE

A MONETARY

( Re v . 0 7 1 0 3 ) RECEI PTS

CHECKTHI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELAT I ONSH I P AMOUNT q I F FOR


( MM1DO/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SER

NUMBER I NCOME

73 6 /0

? I D#J o e B u r k l e

$ 23 . 3 88 / 2 7 , 9 / 1 EK# 1 4 4 2 1 B r y n Mawr

9/ 24/ 04 U r b a n d a l e , I A 50 32 3 7 x $ 3 . 3 4 =

I D#J e a n Bl o omb u r g

CK# 4 6 3 8 El m 4 2 . 0 0Wes t Des Mo i n e s , I A 50265 7 x $ 6 . 0 0 =

I D#" Ro n P a i n e

CK# 1 0 5 7 7 E i m c r e s t Dr2 6 . 2 5

Wes t De s Mo i ne s I A 50325 7 x $ 3 . 7 5 =I D#

Ra y Da v i sCK# 1 2 9 2 6 T i m b e r l i n e Dr

2 2 ' 8 9

U r b a n d a l e , I A 5 0 3 2 3 7 x $ 3 . 2 7 =

I D#Kev i n Ho v i c k

CK# 1 3 5 6 0 L a k e S h o r e Dr1 7 . 5 0

C l i v e , I A 5 0 3 2 5 7 x $ 2 . 5 0 =

I D #Ro n J e a n

CK# 2214 Ri d g ewo o d Dr 3 8 . 5 0A l t o o n a , L A 7 x $ 5 . 5 0 =

I D #B r u c e K e l l e y

CK# 1 4 Gl e n v i e w Dr 1 3 4 . 6 1

De s Mo i n e s , I A 50312 7 x $ 1 9 . 2 3 =

I D #Wi l l i a mA. Mu r r a y

CK# 1 7 7 0 Bi r c h wo o d C i r c l e 2 2 ' 7 5

Wau ke e, 1 A 5 0 2 6 3 7 x $ 3 . 2 5 =

I D#Dave Na r i g o n

CK# P . O. Bo x 3 0 81 4 0 . 0 0

Mon r o e I A 50170 7 x $ 2 0 . 0 0 =I D#

D e n n i s C h r i s t y

CK# 1 8 0 1 NW8 1 s t S t 2 2 . 7 5

C l i v e , I A 50 32 5 7 x $ 3 . 2 5 =



/ 1 8/ 2 00 4 0 8 : 4 0 FAX 5152802754 EXC I NSURANCE EXECUTI VE a 00 8

Fo r I n s t r u c t i o n s , Se e Bac k o f Fo r m



COMMI TTEE NAME ( Mu s t b e s ame a s o n St a t eme n t o f O r g a n i z a t i o n )

Emp l o y er s Mu t u a l C a s u a l t y Co . P o l i t i c a l Ac t i o n Comm . f o r Re s p on s i b l e S t a t e Gov


STATECANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROMA STATE PAC ( P OL I T I C AL ACTI ON COMMI TTEE) , L I S T THE PAC I DENTI F I CATI ONNUMBER AND THEPAC CHECK NUMBER I N THE DESI GNATED COLUMN A L I S T OF I D NUMBERS I S AVAI LABLE FROMTHE I OWA ETHI CS AND CAMPAI GN

DI SCLOSURE BOARD

CAUTI ON : S e c t i o n 6 8B . 3 2 A ( 6 ) , I o wa Code , p r o h i b i t s t h e u s e o f i n f o r m a 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 an y c o mme r c i a l p u r p o s e b y an y 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 I $ 2 2 3 . 7 2

` 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 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 b y 5 6m a r r i a g e ) I f s u mame 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 f - _

f 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 )

SCHEDULE

A MONETARY

( R e v , 0 7 1 0 3 ) RECEI PTS

QCHECKTHI S BOX I F

AMENDI NGFORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT 4 I F FOR


( MM/ DD/ YR) AND PAC CHECK ( i f a p p l i c a b l e ) RAI SER

NUMBER I NCOME

7 / 36 , 8 / 1 '; D#

L on n i e Sc hwab$ 2 4 . 5 0

8 / 2 7 , 9 / 1CK#

P . O . Box 47 5

9/ 24/ 04 Wa u k e e , 1 A 5 0 2 6 3 7 x $ 3 . 5 0 =

I D#J i m F o n t a n i n i

1 1

CK# 9 2 9 4 3 r d S t42 . 0 0

We s t De s Mo i n e s , I A 5 02 6 5 7 x $ 6 . 0 0 =

I D#Ti mWy l d e r

CK# 8 51 2 Ho r t o n Av e1 6 . 1 7

De s Mo i n e s I A 7 x $ 2 . 3 1 =

I D#Bob Ne s wo l d

CK# 1 8 7 5 2 n d S t2 2 . 6 1

We s t De s Mo i n e s , I A 5 0 2 6 5 7 x $ 3 . 2 3 =

I D#S c o t t Be h r e n s

1 6 . 8 0" CK# 416 Gr a n d Av e

We s t De s Mo i n e s , I A 5 0 2 6 5 7 x $ 2 . 4 0 =

I D#De b r a Cu n n i n g h am

CK# 180 4 5 7t h St 2 2 . 7 5De s Mo i n e s , I A 5 0 3 10 7 x $ 3 . 2 5 =

I D#S h a r i S c o o n o v e r

CK# 1443NW1 0 4 t h 1 0 . 5 0

C l i v e , I A 5 0 3 2 5 7 x $ 1 . 5 0 =

I D#Scan P e l l e t i e r

i tCK# 1 3 9 2 7 Br y n Mawr Dr

2 2 ' 8 9

Ur b a n d al e , I A 5 0 3 2 3 7 x $ 3 . 2 7 =

I D#Ch r i s H a t c h i t t

CK# 1315 HyVue St2 8 . 0 0

A d e l I A 50003 7 x $ 4 . 0 0 =

I D#Ro b e r t Gr e e d y

CK# 1104 Cl a r k 1 7 . 5 0. ,

Ames , 1A5 001 0 7 x $ 2 . 5 0 =



/ 1 8 / 2 00 4 0 8 : 40 FAX 5 1 5 2 8 0 2 7 5 4 EMC I NSURANCE EXECUTI VE 80 0 9

F o r I n s t r u c t i o n s , Se e B a c k o f Fo r m


( 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 ( M u s t b e s am e a s o n St a t e me n t o f O r g a n i z a t i o n )

Emp l o y e r s Mu t u a l Ca s ua l t y Co . P o l i t i c a l Ac t i o n Comm. f o r Re s po n si b l e S t a t e Go v

STATE CANDI DATES NOTE : I F A CONTRI BUTI ON I S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACT I O N C OMMI T T E E ) , L I S T THE PAC I D EN T I F I C A T I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN A L I S T OF I D NUMBERS I S A V A I L A B L E FROM THE I OWA E T H I C S AND CAMPAI GN

DI SCLOSURE BOARD .

CAUTI ON: S e c t i o n 6 8B . 3 2 A ( 6 ) . I o wa Co d e, p r o h i b i t s t h e u s e o f i n f o r m a t i o n c o p i e d f r o m r e p o r t s a n 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 y c o mme r c i a l p u r p o s e b y a n y 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 I $ 1 0 7 . 5 2

TOTAL ( 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 ma 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 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 b y 6 6ma 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 same 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 f - _ .

f 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 )

SCHEDULE

A MONETARY

( Re v . 0 7 / 0 3 ) RECEI PTS

CHECKTHI S BOX I F

AMENDI NG FORM

DATE PAC I D NUMBER NAME AND ADDRESS OF CONTRI BUTOR RELATI ONSHI P AMOUNT d I F F OR

RECEI 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 SER

NUMBER I NCOME

7 / 3 , 0 1 I D #D e a n a C l a r k

$ 2 2 . 7 58/ 27, 9/ 1 EK# P . 0 . Bo x 2 4 89/ 24/ 04 Mo n r o e , I A 5 0 1 7 0 7 x $ 3 . 2 5 =

I D#Ka t h l e e n Kn u t s e n

2 2 ' 7 5CK# 2 5 0 0 As h wo r t h RdWes t De s Mo i n e s , I A 5 0 2 6 5 7 x $ 3 . 2 5 =

I D#A l i s o n Ca t e

CK# 6 7 0 9 Co mp t o n Ct7 . 0 0

J o h n st o n I A 5 0 1 3 1 7 x $ 1 . 0 0 =I D#

Ma r k Reese

CK# 4 7 6 5 NWL ov i n gt o n Dr3 2 ' 2 7

De s Mo i n e s , I A 5 0 3 1 0 7 x $ 4 . 6 1 =I D#

Ma r k F e r n e r2 2 ' 7 5

CK# 4 7 5 3 8 5 t h S t

Ur b a n d a l e , I A 5 0 3 2 2 7 x $ 3 . 2 5 =I D #

CK#

I D #

CK#

I D#

CK#

I D #

CK#

I D#

CK#



/ 1 8/ 2 00 4 08 : 41 FAX 5 1 5 2 8 0 2 7 5 4 EMC I NSURANCE EXECUTI VE Z 0 1 0

T HI S BOX APPL I ES 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 $ 500 o r mo r e m u 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 l 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 er 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 m u s t a l s o b e d e t a i l i t e mi 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 p e 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 mm i t t e e . ( R e f e r t o

S 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 )

FOR I NSTRUCTI ONS, SEE BACKOF FORM SCHEDULE

EXPENDI TURESB MONETARY

- - MONEY SPENT FROM COMMI TTEE ACCOUNT ( R e v . 0 7 / 0 3 ) EXPENDI TURES

STATE PAC COMMI TTEES : NOTE : FOR CONTRI BUTI ONS MADE TO STATEWI DE OR L E GI S L AT I V ECHECKTHI S BOX I FCANDI DATES, L I S T THE CANDI DATE I D E N T I F I C A T I ON NUMBER I N THE DESI GNATED COLUMN AND THE

PAC CHECK NUMBER FOR EACH EXPENDI TURE . A L I S T OF I D NUMBERS I S AVAI LABLE FROM THE I OWA AMENDI NG FORMETHI CS & CAMPAI GN DI SCLOSURE BOARD

COMMI TTEE NAME ( Mu s t b e s am e a s o n St a t e me n t o f O r g a n i z a t i o n )

E mp l o y e r s Mu t u a l Ca s u a l t y Co . P o l i t i c a l A c t i o n Comm. f o r R e s p o n s i b l e S t a t e Go v e r nme n t

CANDI DATE NAMEANDADDRESS TOWHOM PURPOSE AMOUNT

DATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

EXPENDED ( 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( MMI DDf YR) AND PAC

CHECK

NUMBER

I D#5 6 4 Mu r p h y f o r S t a t e R e p r e s e n t a t i v e Campa i g n C o n t r i b u t i o n

0 7 - 1 9 - 0 4CK#

1 5 5 NGr a n dv i e w A v e n u e$

1 0 0 . 0 01 0 3 9 Du b u q u e , I A 5 2 0 0 1 - 6 3 2 5

I D# 9 8 4 B e h n f o r S e n a t e Campa i g n C o n t r i b u t i o n

0 7 - 2 1 - 0 4 CK# 1 0 4 0 1 3 1 3 Q u i l l Av e 1 5 0 . 0 0B o o n e , I A 5 0 0 3 6

I D# 9 52 L u n d b y f o r I o wa S e n a t e Campa i g n C o n t r i b u t i o n

0 8 - 1 3 - 0 4 P . 0 - Bo x 5 6 3 1 0 0 . 0 0CK# 1 0 4 1 Ma r i o n , I A 52302

I D#8 4 0 De a r d e n f o r S t a t e S e n a t e Co mmi t t e e Campa i g n C o n t r i b u t i o n

0 8 - 3 1 - 0 4CK#

3 1 1 3 K i n s e y A v e n u e 1 0 0 . 0 01 0 4 2

De s Mo i n e s , I A 50317

I D# 1 2 3 1 Ge o r g e E i c h h o r n f o r I o wa H o u s e Campa i g n C o n t r i b u t i o n

0 9 - 0 1 - 0 4CK#

P . 0. Bo x 1 4 0 1 0 0 . 0 01 0 4 3 S t r a t f o r d , I A 50249

I D#

CK#

I D#

CK#

I D#CK#

SUB- TOTAL $

TOTAL ( i f l a s t p a g e o f t h i s s c h e d u l e ) $550 . 0 0

employers mutual casualty co pac__6033__scanned

Documents

employers mutual casualty co pac6033scanned