Waiver
Uploaded by
Zach EdwardsWaiver
Uploaded by
Zach EdwardsIOWA ETHICS & CAMPAIGN DISCLOSURE BOARD
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PETITION FOR WAIVER OF CIVIL PENALTY
Name of individual, committee, organization, or client assessed penalty:
______________________________________________________________________________
Name of person submitting petition: ________________________________________________
Address: ________________________________________
________________________________________
Phone or email: ___________________________________
Rule number seeking waived: ________________________
Due date of report: ___________________
Date report filed: ___________________
Amount of penalty: __________________
Date Civil Penalty Assessment Order received: __________________________
Provide the specific and detailed reasons/circumstances that prevented timely filing of the report
and that justify a waiver of the civil penalty rule (or attach additional sheet):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I hereby attest to the accuracy and truthfulness of the information contained herein:
_____________________________________ __________________
Petitioner’s Signature Date
Return completed form to: Iowa Ethics and Campaign Disclosure Board, 510 E. 12th Street, Suite 1A, Des Moines,
IA 50319
