Transcript
FOR INSTRUCTIONS, SEE BACK OF FORM
COMMITTEE NAME (Must be same as on Statement of Organization) Cedar Rapids Physician-Hospital Political Action Committee IMPORTANT : Indicate by # type of committee you are reporting for : ( 1 )Statewide/Legislative/Judge Standing for Retention Candidate ( 2 )State PAC ( 3 )State Party ( 4 )County Central Committee ( 5 )County Candidate ( 6 )City Candidate ( 7 )School Board or Other C ( 9 )City RAG F1Q) t+ I Board or Other Political Political Subdivision Candidate ( 8 )Cbu ' ) Subdivision PAC ( 11 ) Local B allot 15sue ~ .`~. CANDIDATE COMMITTEES ONLY : Candidate Name Office Sought
DISCLOSURE SUMMARY PAGE
FORM
(Rev . 07/2004) Comm . # Logged In Scanned Computer Audited
DR-2
I
DISCLOSURE REPORT
tical Party (if applicable)
Di trict (if Senate or House)
Late reports are subject to possible civil and criminal penalties .
TELEP ONE October 19, 2004 (report date)
371;d2 I's -/D(
DATE SIGNED
!b /G D
I AM FILING A
REPORT FOR (1) ELECTION /(2)NON-ELECTION YEAR . Indicate by # /
Z
FICHECK IF AMENDMENT TO REPORT DATED F~ Check if this is final (termination) report and attach Notice of Dissolution Form DR-3 . (You must continue to file reports until a DR-3 is filed .)
Local Committees, enter Date of Election County & Local Committees, enter County in which Election is held
STATEMENT OF CASH ON HAND CASH ON HAND at the beginning of the reporting period . (Total of all funds held by the committee . This amount MUST be the same as the cash on hand at the end of the last reporting period or must be zero if this is first report filed .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ADD TOTAL MONEY TAKEN IN THIS PERIOD Schedule A : Cash Contributions total (Attach Schedule A) (*also see in-kind below) . . . . . . . . . . Schedule F : Loans Received total (Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Schedule H : Total Sales of Campaign Property (Attach Schedule H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Schedule H applies to Candidates' Committees Only) SUB-TOTAL . . . . . $ SUBTRACT TOTAL MONEY SPENT THIS PERIOD Schedule B : Expenditures total (Attach Schedule B) (**also see debts and loans below) . . . . Schedule F : Loan Repayments total (Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CASH ON HAND at the end of this reporting period (if final report balance must be zero) (Attach DR-3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ **UNPAID BILLS (From Schedule D - Attach Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ *IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedule E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ **OUTSTANDING LOANS (From Schedule F-Attach Schedule F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ CANDIDATE COMMITTEES ONLY : CONSULTANT BREAKDOWN (Schedule G Attached?) VALUE OF CAMPAIGN PROPERTY (From Schedule H - Attach Schedule H) YES $ N/A NO
2,000.00 750.00
0 .00 0 .00
2,750.00
0 .00 0 .00
2,750.00
0 .00 0 .00 0 .00
For Instructions, See Back of Form CONTRIBUTIONS -- MONEY TAKEN IN (Including candidate's personal funds) COMMITTEE NAME (Must be same as on Statement of Organization)
Rese t Form
SCHEDULE (Rev . 07/03)
A
MONETARY RECEIPTS
Q
CHECK THIS BOX IF AMENDING FORM
Cedar Rapids Physician-Hospital Political Action Committee
THE PAC IDENTIFICATION STATE CANDIDATES NOTE : IF A CONTRIBUTION IS RECEIVED FROM A STATE PAC (POLITICAL ACTION COMMITTEE), LIST 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. for soliciting contributions or CAUTION : Section 68B.32A(6), Iowa Code, prohibits the use of information copied from reports and statements for any commercial purpose by any person other than statutory political committees .
DATE RECEIVED (MM/DD/YR)
PAC ID NUMBER (if applicable) AND PAC CHECK NUMBER ID# CK# ID#
NAME AND ADDRESS OF CONTRIBUTOR
RELATIONSHIP TO CANDIDATE" (if applicable)
AMOUNT RECEIVED
v IF FOR
FUNDRAISER INCOME
7/31/04
Dean H . Gesme, Jr . 4365 Fox Meadow Dr. SE Cedar Rapids, IA 52403 Mark J. Tyler 7 High Ridge CT SE Cedar Rapids, IA 52403 Jeanette Werling 2533 Blue Ridge Dr NE Cedar Rapids, IA 52402 Cindy Roehr 320 McKinsie CT NE Cedar Rapids, IA 52402
$250 .00
7/31/04
CK# ID#
100.00
8/15/04
CK# ID#
300.00
8/15/04
CK#
100 .00
- D#
CK# ID# CK# ID# CK# ID# C K# ID# C K# ID# CK#
F
SUB-TOTAL
TOTAL (if last page of this schedule)
' 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 familial relationship, enter "not applicable" in the relationship column . Page
1 of _ A) (for Schedule
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