Fill and Sign the Wwwtaxnygovformsincomeextensionsincome Tax Applications for Filing Extensions

FORM ID Type Status Name DR-1 : Statement of Organization 17614 County Candidate Amended Harney for Supervisor Form DR-1 Web Reporting System For Office Use Only Comm . # Indexed Audited Computer 3d/Amended Date 1/18/2006 Committee Treasurer Name Brenda M. Parker Address 2797 Hwy 1 NE Iowa City, IA 52240 Primary Ph. (319) 354-7682 Secondary Ph. e-Mail icparker@msn .co m Purpose Re-Election Campaign Committee Office Sought : County Supervisor Party: Democratic County : Johnson Primary Bank Account Name Hills Bank and Trust Company Address 1009 2nd St. Account Type Checking Account Name Harney for Supervisor Statement of Organization Rev . 09/2003 17614 Committee Chair Name Ted Pacha Address 4640 Lower West Branch Road SE Iowa City, IA 52240 Primary Ph . (319) 338-9632 Secondary Ph. e-Mail District: 0 Year Standing for Election : 2004 Date of Election : 6/8/2004 Candidate name & address Name Pat L. Harney Address 2771 Hyw 1 NE Iowa City, IA 52240 Primary Ph . (319) 351-1954 e-Mail pjhar@mchsi .co m Statement of Affirmation By Treasurer and Candidate ; or Political Committees, By Chairperson STATEMENT OF AFFIRMATION: By filing this document the committee affirms the following : 1 . The committee and all persons connected with the committee understand that they are subject to the laws in Iowa Code chapters 68A and 68B and the administrative rules in Chapter 351 of the Iowa Administrative Code . 2. That Iowa Code section 68A.6 and rule 351-4.9 require the filing of disclosure reports and that the failure to file these reports on or before the required due dates subjects the candidate or chairperson (in the case of committees other than a candidate's committee) to the automatic assessment of a civil penalty and the possible imposition of other criminal and civil sanctions. 3. That Iowa Code section 68A.14 and rules 351-4 .38 through 4.43 require the placement of the words "paid for by" and the name of the committee on all political materials except for those items exempted by statute or rule. 4. That Iowa Code section 68A.15 and rules 351-4.44 through 4.52 prohibit the receipt of corporate contributions by all committees except for statewide and local ballot issue PACs . 5. A candidate and a candidate's committee may only expend campaign funds as permitted by Iowa code sections 68A.40 through 68A.42 and rule 351-4.25. 6. That the committee will continue to file disclosure reports until all activity has ceased, committee funds spent, debts resolved, and a final report and a statement of dissolution (DR-3) has been filed . Candidate : (signature and date) -------------------------------------------Treasurer: (signature and date) IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD 1510 EAST 12th, SUITE 1A I DES MOINES, IA 50319 1(515) 281-4028