Form C - Lobbyist'S Client Annual Report - Mississippi Secretary Of State
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2C
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 Client Annual Report
page 1 of 2
For office use only. Do not write in this space.
GENERAL INSTRUCTIONS
:
1. Type or print information in black ink.
2. Complete all information, indicate n/a for information that does not apply.
3. Have completed report notarized.
4. Mail or deliver completed, notarized original report and two (2) copies to:
Mississippi Secretary of State, Attn: LOBBYIST REGISTRATION
401 Mississippi Street, Post Office Box 136
Jackson, Mississippi 39205-0136
Quick Logged / Initials
(601) 359-6353 [phone] (601) 359-1499 [fax]
Processed by / date
(Incomplete forms or forms submitted without signatures or notary seal will be returned.)
Form may be faxed by deadline without penalty if followed up via U.S. Mail or handmail.
Itemized entry / date
SECTION A: Identification
1.
Lobbyist’s Client
2.
Permanent Mailing Address
City
State
Zip
3.
Permanent Phone
4.
Fax
5.
E-mail/Other Phone
(
)
(
)
6.
Cycle Year
7.
Type of Report
TERMINATING Report
ORIGINAL Annual
AMENDED Annual Report
(ending activity prior to
Report (report due
(report returned to you for
th
December 31)
January 30
for the
correction)
previous year’s activity)
SECTION B: Administrative Operation Costs
8.
List below the names of all LOBBYISTS registered by you during
9.
Total compensation for all Lobbyists
0.00
$
this calendar year and total compensation for each lobbyist.
If
as identified in Item 8a.
activity terminated before 12/31, indicate the termination date.
$
10. Reimbursement(s) to Lobbyists
Lobbyist Name, Certificate No., Early Term. Date
Compensation
$
$
11. Overhead
$
$
12. Direct Payments
$
$
13. Lobbying Expenses
$
14. Urging others to communicate
$
(advertising, direct mail, etc.)
$
$ $ $ $
0.00
TOTAL
$
15.
, Section B
0.00
8a.
Total
$
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