Form E - Lobbyist'S Legislative Expenditure Report - Office Of The Mississippi Secretary Of State

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E
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
FORM
ERIC CLARK, Secretary of State,
401 Mississippi Street, Post Office Box 136, Jackson, Mississippi 39205-0136
Lobbyist’s Legislative Expenditure Report
page 1 of 1
For office use only. Do not write in this space.
INSTRUCTIONS
:
1.
This report is required by Miss. Code Ann. §5-8-11(6) (1972). You must file even if you
have no expenditures.
2.
Type or print information. Complete a separate report for each lobbyist registration.
3.
Incomplete report or reports submitted without signature will be returned.
4.
Reports must be received in the Secretary of State's Office by the deadline.
5.
Mail or deliver completed, signed report to:
Mississippi Secretary of State, Attn: LOBBYIST REGISTRATION
401 Mississippi Street, Post Office Box 136
Jackson, Mississippi 39205-0136
Quick Log / Initials
(601) 359-6353 [phone] (601) 359-1499 [fax]
Processed by / date
Form may be faxed by deadline without penalty if followed up via U.S. Mail or handmail.
Itemized entry / date
SECTION A. Registration Information
1.
LOBBYIST
2.
LOBBYIST’S CLIENT
Mid-Session
due Feb. 25
3.
Certificate Number
4.
Cycle Year
5.
Type of
(Legislative convening date through Feb. 25,
)
Report
End-of-Session
due 10 days after sine die
(Feb. 25 through sine die,
)
Amended Report
(Also check Mid-Session or End-of-Session)
SECTION B. Itemized Expenditures
TO COMPLETE THIS SECTION
:
1.
In the column marked “Recipient,” disclose the public official or employee receiving anything of value or other payment during the period of the
report. If someone other than the public official or employee is given or promised the thing of value on behalf of the official or employee, report that
person’s name also. DO NOT INCLUDE receptions as defined in Miss. Code Ann. §5-8-11 (7)(a) (1972).
2.
In the column “Recipient’s Office Title,” disclose the public office, position, or title the recipient holds. Disclose the “Date” and “Place” the item
was given, the “Provider,” a “Description” of the item, and its “Value/Cost.”
3.
If additional space is required for itemized expenditures, complete and attach Form XL (Itemized Legislative Expenditures).
Recipient’s Office
Recipient
Date
Place
Provider
Description
Value/Cost
Title
$
$
$
$
0.00
TOTAL, this page
$
XL
Attached Form
Lobbyist’s Signature
I certify that the above information is true and correct, according to my knowledge, information, and belief.
Print name here. ________________________________Signature _____________________________________ Date________________
th
PENALTY NOTIFICATION: Beginning the tenth (10
) calendar day after statutory deadlines, fines of fifty dollars ($50.00) per day are
assessed for delinquent reports. Miss. Code Ann.§5-8-17(1) (1972).
Form E [rev. Jun-02}

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