FORM DR-1: Statement of Organization Form Statement of

ID 6279 DR-1 Organization

Type Iowa PAC Web Reporting System Rev. 09/2003
Status Amended For Office Use Only
Name Iowa Ophthalmology P.A.C. Comm. # 6279
Indexed
Filed/Amended 7/7/2007 Audited
Date Computer

Committee Treasurer Committee Chair

Name Christopher F. Blodi Name C. Rommel Fuerste
Address 1501 50th Street Address 2140 John F. Kennedy Rd.
Suite 133
West Des Moines, IA 50266- Dubuque, IA 52002-
Primary Ph. (515) 226-0702 Primary Ph. (319) 582-0769
Secondary Ph. (515) 222-6400 Secondary Ph. (319) 556-1684
e-Mail cblodiirc@aol.com e-Mail
Purpose
to support candidates for state elective office who are interested in medical eye care issues and matters
related to the practice of ophthalmology.

Office Sought: District:

Party: Year Standing for Election:
County: NA Date of Election:
Primary Bank Account PAC Parent Entity, Affiliate or Sponsor
Name American Chartered Bank Name Iowa Academy of Ophthalmology, Inc.
Address 459 S. Rand Rd. Address Administrative Office
10 W. Phillip Rd., Suite 120
Lake Zurich, IL 60047
Account Type Checking Primary Ph. (847) 680-1666
Account Name Iowa Ophthalmology PAC e-Mail EyeOrg@aol.com

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.

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Chair Person: Treasurer:
(signature and date) (signature and date)

IOWA ETHICS AND CAMPAIGN DISCLOSURE BOARD | 510 EAST 12th, SUITE 1A | DES MOINES, IA 50319 | (515) 281-4028
 Filed/Amended
Committee Accounts 7/7/2007
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Default
Checking Iowa Ophthalmology PAC
1 American Chartered Bank
Default Account 459 S. Rand Rd.

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Other
Checking Iowa Ophtalmology P.A.C.
2 Citibank
700 N. Milwaukee Ave.

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 Filed/Amended
Committee Officers 7/7/2007

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Role Name and Address

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 Filed/Amended
DR-1 Auditors Notes 7/7/2007

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