Form X - Itemized Expenditures - Mississippi Secretary Of State
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1X
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
FORM
ERIC CLARK, Secretary of State,
401 Mississippi Street, Post Office Box 136, Jackson, Mississippi 39205-0136
Itemized Expenditures
For office use only. Do not write in this space.
INSTRUCTIONS
:
1.
Use this form if you need additional space for itemized expenditures on Lobbyist’s
Annual Report (Form A) or Lobbyist’s Client Annual Report (Form C).
2.
If you have no itemized expenditures, do not file this form.
3.
Provide the name of the recipient, the recipient’s office title, date, place, provider,
description, and the value or cost of anything of value given or promised to a public
official or employee during the indicated period.
Itemized entry / date
4.
This form may be copied as needed.
5.
ONLY individual names may be reported as the “Recipient.”
Registration Information
1.
LOBBYIST
2.
LOBBYIST’S CLIENT
3.
Certificate Number
4.
Cycle Year
5.
Type of
Lobbyist’s Annual Report (Form A)
Report
Lobbyist’s Client Annual Report (Form C)
Recipient
Recipient’s Office Title
Date
Place
Provider
Description
Value/Cost
1.
$
2.
$
$
3.
$
4.
$
5.
$
6.
$
7.
$
8.
$
9.
$
10.
$
11.
$
12.
$
13.
$
14.
$
15.
$
16.
$
17.
$
18.
$
19.
$
20.
0.00
$
TOTAL, this page
page ____ of____
Form X
[rev. Jun-02}
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