o'brien john1314scanned

8/7/2019 O'Brien John__1314__scanned

1/7

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COMM~I EE NAME ( Mu s t ~ b e s ame a s o n St a t emen t o f O r g a n i z a t i o n )- t 7 c ~l U Of i J ~ l Y - l ~ . VI MPORTANT : I n d i c a t e 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 :( 1 ) S t a t e w i d e / L e g i s l a t i v e C a n d i d a t e ( 2 ) S t a t e w i d e PAC ( 3 ) S t a t e P a r t y ( 4 ) C o u n t y / L o c a l C a n d i d a t e( 5 ) C o u n t y PAC ( 6 ) B a l l o t I s s u e / F r a n c h i s e C o mm i t t e e ( 7 ) C o u n t y / C i t y C e n t r a l C o mm i t t e e( 8 ) S u p p o r t S I t o o f C an d i d a t e sJ , ~ jCZ~At Me~j" 7( - - 2 - 2z~ - 3 - 0 ( ` 7 l O

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h e 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 an 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 F o r m DR- 3 .( Y o u mus 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 N o t i c e o f D i s s o l u t i o n i s f i l e d . )

STATEMENT OF CASH ON HANDCASH ON HANDa 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 h i s i s t h e t o t a lo f a l l mo n i e s h e l d b y t h e c o mmi t t e e . T h i s amou n t MUST b e t h es ame a s t h e c a s h o n h an d a t t h e e n d o 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 mus 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 . ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

ADDTOTALMONEYTAKEN I N THI S PERI ODSc h e d u l e A: Ca s h C o n t r i b u t i o n s t o t a l ( A t t a c h Sc h e d u l e A ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d u l e F : L o a n s Re c e i v e d t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d u l e H : T o t a l Sa l e s o f Campa i g n P r o p e r t y ( A t t a c h Sc h e d u l e H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

( Sc h ed u l e H a p p l i e s t o Ca nd i d a t e s ' Commi t t e es On l y )SUB- TOTAL . . . . . . $

SUBTRACT TOTAL MONEYSPENT T HI S PERI ODSc 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 Sc h e du l e B ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sc h e d u l e F : L o a n Re p a yme n t s t o t a l ( A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 i o d ( i f f i n a l r e p o r t , b al a nc e mus tb e z e r o ) ( A t t a c h DR- 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

UNPAI D BI L L S ( F r o mSc h e du l e D - A t t a c h Sc h e d u l e D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $aI N K I ND CONTRI BUTI ONS ( F r o m Sc h e d u l e E - A t t a c h Sc h e du l e E ) . . . . . . . . : f . . . .v. . . . . $OUTSTANDI NG LOANS ( F r o m Sc h e du l e F - A t t a c h Sc h e d u l e F ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

, NDI DATE COMMI TTEES ONLY :CONSULTANT 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 Sc h e d u l e H - A t t a c h Sc h e d u l e H )

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0 , W_ I e / J 1 ~ - o r ,- - 5 , ; a +- e 5 - e t i l a - f ~CO. K i n .STATE CANDI DATES NOTE: I F A CONTRI BUTI ON 1 S RECEI VED FROM A STATE PAC ( P OL I T I C A L ACTI ON COMMI TTEE) , L I S T THE PAC I D EN T I F I C AT I ONNUMBER AND THE PAC CHECK NUMBER I N THE DESI GNATED COLUMN. A L I S T OF 1 D NUMBERS I S AVA I L ABLE FROM THE I OWA ETHI CS AND CAMPAI GNDI SCLOSURE BOARD .CAUTI ON : Se 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 op i e d f r o m r e p o r t s a n d s t a t e me 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 rf o r a ny c omme r c i a l p u r p o s e by 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 .

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4/7

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5/7

T HI S BOX APPL I ES TO CANDI DATES' COMMI TTEES ONLY:Pu 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 Sc h e d u l e H . ( R e f e r t o Sc h e d u l e H i n s t r u c t i o n s . )

) 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 no c h e du 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 ma d e 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 oSc h e d u l e G i n s t r u c t i o n s a n d I o wa Co d e 5 6 . 6 ( 3 ) ( i ) . )

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CANDI DATE NAME AND ADDRESS TOWHOM PURPOSE AMOUNTDATE I D NUMBER EXPENDI TURE ( DESCRI BE TRANSACTI ON) EXPENDED

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