PON : LOREtl CHIJPCH FA ;: HO . : 641 447 2644 Mar.

22 2005 11 :48Pf1 P1
7 ;
FOR INSTRUCTIONS, SEE BACK OF FORM
FORM
DISCLOSURE SUMMARY PAGE DR-2 DISCLOSURE
COMMITTEE NAME (Must be same as on Statement of Organization) (Rev. 07/2004) REPORT

For OMCj Use Only

Church For Auditor
comm . it 76,-2 7
IMPORTANT: Indicate by # type of committee you are reporting for.
( 1 )Statewide/Leglgtative/Judge Sunding for Retention Candidate (2F5)State
- 1 Logged in
PAC ( 3 )State Party
(4 )County Central Committee ( S )County Candidate ( 6 )City Candidate ( 7 )School Board or Other Scanned
Political Subdivision Candidate (8 )County PAC (9 )City PAC ( 10 )School Board or Other Political Computer 7"Z
Subdivision PAC (11) Local Ballot issue
Audited
CANDIDATE COMMITTEES ONLY: -
Candidate Name Political Party (if applicable)
Judv Church Late reports are subject to
. Democratic
possible civil and criminal
Office Sought District (if Senate or House) penalties .
' Clarke County Auditor

TELEPHONE DATE SIGNED

1 AM FILING A Final REPORT FOR (1) ELECTION I(2)NON-ELECTION YEAR .

(report date) Indicate by #

EICHECK IF AMENDMENT TO REPORT DATED Local Committees, enter Date of Election

November 2, 2004
Check if this is final (termination) report and attach Notioo of Dissolution Form DR-3 . County & Local Committees, enter County In
(You must continue to file reports until a DR,3 is filed.) which Election is held
Clarie

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 .) . . . . . . .. . . . . . . .., . . . . . .. . .  . . . . . . $ 5.19

ADD TOTAL MONEY TAKEN IN THIS PERIOD

Schedule A : Cash Contributions total (Attach Schedule A) ('also see in-kind below) . . . . . . . ., . -0-
Schedule F: Loans Received total (Attach Schedule F) . . . . . . .. .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . . . . -0-
Schedule H : Total Sales of Campaign Property (Attach Schedule H) . . . . . . . . . ., . . . . ., . . . ... . . . .., .. . . .
- (Schedule H applies to Candidates' Committees Only)

SUB-TOTAL . . . . . $ 5 .19
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) . . . . . . . . . . . . . .. . . . .. . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 5 .19
CASH ON HAND at the end of this reporting period (if final report balance must
be zero Attach DR-3 -U-

"UNPAID BILLS (From Schedule D -Attach Schedule D) . .. . .. . . . . .. . . . ., . . . . . . . . . . . . . .. . . . . . . . . ., . . ., ., . . . . ._ . . . . . . ., .$ -0-

'IN KIND CONTRIBUTIONS (From Schedule E - Attach Schedule E) . . . . .. . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . .$ 194.81
'OUTSTANDING LOANS (From Schedule F-Attach Schedule F) . . . . . . . . .. . .. . . . . ., ., . . . ., .  . ., . .  , .  ,., .,$ -0-
CANDIDATE COMMITTEES ONLY :
CONSULTANT BREAKDOWN (Schedule G Attached?) ® YES ENO
VALUE OF CAMPAIGN PROPERTY (From Schedule H -Attach Schedule H) $
FOR 1NSTRUCTfONS, SEE BACK OF FORM
SCHEDULE

COMMITTEE NAME(Alust De seme as on Statement ol0rgonizaGlon) F LOANS

(Rev .07103) RECEIVED
Church For Auditor 6 REPAID

NOTE ; This schedule reports money loaned to the committee which Is deposited In the commIltea accounl.
I CHECK THIS BOX IF
AMENDING FORM
TOTAL UNPAID LOANS FROM LAST REPORTING PERIOD $ 200.00 _-___---~--

PART I- MONETARY LOANS RECEIVED _THIS REPORTING PERIOD PART 11 - MONETARY LOAN REPAYMENTS MADE THIS REPORTING PERIOD
(Odglnal source olfoan, such as a bank, must be shown If a third party is (Loans forgiven must bo reported can Sehadula E - M,kfnd Conl4b0bns.)
Involved . Include loans from cendkfato's personal funds.)
DATE NAME AND ADDRESS OF LENDER RELATIONSHIP AMOUNT DATE PAID NAME AND ADDRESS OF LENDER RELATIONSHIP AMOUNT
RECEIVED (Include Endorser's Name, 11 Apptirabla) TO CANDIDATE OF LOAN (Mh11DDlYR) (Include Endorser's Name, it Applicable) TO CANDIDATE' EPAID
Mh11DD/YR If A Ilcable' It A licah;a
S S
Judy Church
1699 140th Avenue
211 1/05 Murray, 1A 50174 Self 5,19

TOTAL (FART0 $ 5. 1 9
S TOTAL_ CASH REPAYMENTS (PART 11)

From Schedule E - TOTAL LOANS FORGIVEN s

194 .81

TO fAL OUTSTANDING LOANS END OF REPORT PERIOD

£ .00

'Disclosure law requires candidate commlttses to dlscbose the relationship of any rotative
making a contribution to the oommlttee. Retallonshlp musl be shown to the Third degree of
consangutnlty (blood relatives) and affnlty (relatives by marriage). If surname of contributor Is
the same as candidate, but there Is no famllIal relationship, enter "not applicable" In the
retationshlp column when It applies . Page 1 of )
(for Schedule F)
 COPJT I HUE FROM PREVIOUS PAGE 001

'Disclosure law requires candidates to disclose the relationship of any relative making an in kind contribution to the Page t of
committee . Relationship must be shown to the third degree of consanguinity (blood relatives) and affinity (relatives (for Schedule E)
by marriage) . (See Page 2 of forms packet .) If surname of contributor is the same as candidate, but there is no
familial relationship, enter "not appficeble' in the relationship column .
FROG : LOREN CHURCH FAX NO . : 541 447 2544 Mar . 22 2005 11 :51Ph1 P1

Notice of Dissolution FORM

DR-3
(Rev . 07103)

NOTICE OF
DISSOLUTION
Maul to :
1ECDB
510 Last 12` x', Suite IA For Office Use Only
Des Moincs . Iowa 50319
Comm . #
Indexed
0-
Audited 1'
Computer_ il l
Certified Date of Dissolution

COMMITTEE NAME

Church For Auditor

Official Name of Committee

1699 140th Avenue

Street

Murray, IA 50174

City, State, Zip Code

641 447-2644
L 1
Area Telephone
Code
I I

WHEN TO FILE :
The Notice of Dissolution must be filed within thirty (30) days of completion of all the following:

1. All debts, loans and obligations have been paid or transferred ;

2. All campaign funds have been spent;
3. All campaign property sold or transferred (candidates only); and
4. A final report disclosing all transactions closing the committee,

For state candidates and state PACs, a final bank statement must be filed with the Notice of Dissolution or as soon as
possible if the bank statement is not available at the time the Notice of Dissolution is filed .

Candidate or Treasurer (if candidate's corn mittee)ISignature of Chair or Treasurer (if PAC)

Date Signed

FOR INSTRUCTIONS, SEE BACK OF FORM

This form is not applicable to statutory political committees .