T
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
FORM
ERIC CLARK, Secretary of State,
401 Mississippi Street, Post Office Box 136, Jackson, Mississippi 39205-0136
Termination of Lobbyist Registration
For office use only. Do not write in this space.
INSTRUCTIONS
:
1.
Complete this form as official notice of termination of lobbyist or lobbyist’s client
registration.
2.
File this form with your Annual Report at the time of termination.
.
3.
Type or print all information.
4.
Return this form and your completed Annual Report to:
Mississippi Secretary of State, Attn: LOBBYIST REGISTRATION
401 Mississippi Street, Post Office Box 136
Jackson, Mississippi 39205-0136
(601) 359-6353 [phone] (601) 359-1499 [fax]
Processed by / date
SECTION A: Identification
1.
LOBBYIST’S FULL NAME
2.
Certificate Number
3.
PERMANENT mailing address
City
State
Zip
4.
Permanent Phone
(
)
5.
Fax
(
)
6.
Full name of LOBBYIST'S CLIENT
7.
PERMANENT mailing address
City
State
Zip
8.
Permanent Phone
(
)
9.
Fax
(
)
10. Date of Termination
Statement of Termination
This is to certify that the undersigned lobbyist ceases
This is to certify that the lobbyist noted above ceased to
to engage in lobbying activity for the above noted
engage in lobbying activity for the undersigned
lobbyist's client.
lobbyist's client.
Terminating Annual Report (Form A) MUST be
Terminating Lobbyist’s Client Annual Report (Form C)
attached.
is attached.
Lobbyist's client has other lobbyists, and no annual
report is due at this time.
Print LOBBYIST’S name here.
Print LOBBYIST’S CLIENT name here.
Signature
Date
Signature
Date
Form T, rev. Jun-02