Form T Termination Of Lobbyist Registration 2005
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1T
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE, Eric Clark
FORM
Termination of Lobbyist Registration -
(Accompany with “A” or “C” or both)
For office use only. Do not write in this
Faxed reports must be followed by originals. Please - no copies and no staples.
space.
INSTRUCTIONS
:
1. Complete all information.
How to locate forms on our website
2. Lobbyist and lobbyist's client must sign form.
Elections
3. Terminating “T” – Lobbyist’s Annual Report “A”
Lobbying
must accompany the Terminating “T” form.
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Lobbying Forms Library
Date
4. If the Client has only one Lobbyist, and that
“R” – Registration
“E” – Mid Session
Lobbyist is Terminating, then the “A” and “T” form
“E” – End-of-Session
must also accompany the terminating “C” form.
Lobbying Year
“A” – Lobbyist Annual Report
“C” – Client Annual Report
Mississippi Secretary of State
Begin:
Follow directions for extensions
Lobbying
Attn: LOBBYING
Beginning
Physical:
(No Earlier -
401 Mississippi Street
Jan. 1)
Jackson, Mississippi 39201
Mailing:
Lobbying
End:
Post Office Box 136
Ending
(No Later- Dec.
Jackson, Mississippi 39205-0136
st
31
)
(601) 359-6353 [phone] (601) 359-1499 [fax]
Termination
Date
Lobbyists/Clients must notify our office if there are changes of addresses or phone numbers.
Certificate No.
Write name of Client as it appears on “R” Registration Form. Do not abbreviate.
#
SECTION A: Identification
1.
LOBBYIST’S FULL NAME
2.
Occupation
3.
Physical Address(required)
City (or Country)
State
Zip
4.
Mailing Address
City (or Country)
State
Zip
5.
Permanent Phone
(
)
6.
Fax
(
)
7.
LOBBYIST'S CLIENT (do not abbreviate)
8.
Physical Address(required)
City (or Country)
State
Zip
9.
Mailing Address
City (or Country)
State
Zip
10. Permanent Phone
(
)
11. Fax
(
)
Statement of Termination
This is to certify that the undersigned lobbyist
This is to certify that the lobbyist noted above ceased to
ceases to engage in lobbying activity for the above
engage in lobbying activity for the undersigned lobbyist's
noted lobbyist's client.
client.
Terminating Annual Report (Form A) MUST be
Client employs only this one lobbyist, so terminating
attached.
Lobbyist’s Client Annual Report (Form C) is attached.
Lobbyist's client has other lobbyists, and no Client
Annual Report “C” is due at this time.
Print LOBBYIST’S name here.
Print LOBBYIST’S CLIENT name here.
Signature
Date
Signature
Date
Page 1 of 1
Form T [rev. July-05]
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