Form A - Lobbyist'S Annual Report Page 2
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1
2A
FORM
page 2 of 2
SECTION C: Administrative Operation Costs
SECTION D: Payments to Public Officials / Employees
Disclose expenditure TOTALS for each category
Disclose expenditure TOTALS for each category from January 1
(from January 1 – December 31).
through December 31 of Lobbying year. Any amount other than zero
(0) must be itemized in Section E, below.
22. Overhead
25. Food and beverages, travel
$
$
and lodging. DO NOT
include Receptions – See
Section E.
21. Support
$
22. Employees who
26. Entertainment, gifts,
$
$
communicate with public officials
anything of value, loans,
honorariums
23. Urging others to
$
communicate
TOTAL
TOTAL,
24.
, SECTION C
$
27.
SECTION D
$
SECTION E: Itemized Expenditures and Receptions
28. Itemize information from totals listed in Section D. If additional space is needed, attach FORM X – Itemized Lobbying Expenditures.
Recipient
Recipient’s Office Title
Date
Place
Provider
Item Description
Value/Cost
$
$
X
Attached Form
29.
Itemize information for all receptions as defined in §5-8-11 (7) (a), Miss. Code Ann. (1972). If additional space is needed, attach FORM XP –
Itemized Lobbying Receptions.
Date
Place/Location
Est. No. Public Officials
Est. Total Attendance
Total Reception Cost
$
XP
Attached Form
Lobbyist Signature
Notary Information
State of_____________________
Sworn and subscribed before
I certify that the above information is true and correct,
me this________ day of
according to my knowledge, information and belief.
County of___________________
____________________, _________
Print name here
____________________________________
Country________________________
Notary Public
Signature
Date
My Commission expires
IMPORTANT
•
Miss. Code Ann. §5-8-21 (1972) provides that a conviction for violation of the lobbying law, for the first offense, carries a penalty of a
maximum of six (6) months in jail and a fine of One Thousand Dollars ($1,000); and for subsequent offenses a maximum of three (3)
years in the penitentiary and a fine of Five Thousand Dollars ($5,000).
•
Miss. Code Ann. § 5-8-11(5) (1972) provides that Form A “shall contain information on all expenditures paid or initiated by the
lobbyist on behalf of each lobbyist’s client during the preceding twelve (12) calendar months, and it shall include a cumulative total for
the calendar year of all reportable categories.”
Form A [rev. July-05]
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