Form C - Lobbyist'S Client Annual Report Page 2
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1
2C
FORM
page 2 of 2
SECTION C: Payments to Public Officials / Employees
Disclose expense TOTALS for each category. Any amount other than zero “0” must be itemized in Section D, Item 17.
15. Food or Beverages, Travel, Lodging, and
16. Gifts, loans, honorariums,
TOTAL
17.
, SECTION C
Entertainment. This does NOT include
Any other thing of value
Receptions – see Section D for Receptions.
$
$
$
SECTION D: Itemized Expenditures and Receptions
18. 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
$
$
$
$
TOTAL, this page
$
X
Attached Form
19. 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
$
$
$
$
TOTAL
$
, Reception Costs
XP
Attached Form
Notary Information
Lobbyist’s Client Signature
State of_____________________
Sworn and subscribed before
I certify that the above information is true and
correct, according to my knowledge, information
me this__________ day of
County of___________________
and belief.
______________________ , _________
Print name here
____________________________________
Country of….……………………….
Notary Public
Signature
Date
My Commission expires
____________________________________
PENALTY NOTIFICATION: 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
Form C [rev. July-05]
maximum of three (3) years in the penitentiary and a fine of Five Thousand Dollars ($5,000).
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