Form C - Lobbyist'S Client Annual Report - Mississippi Secretary Of State Page 2
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FORM
page 2 of 2
SECTION C: Payments to Public Officials / Employees
Disclose expense TOTALS for each category. Any amount other than zero “0” must be itemized in Section D, Item 18.
16. Food or Beverages - DO NOT include receptions;
17. Gifts, loans, honorariums,
TOTAL
18.
, SECTION C
Travel and Lodging, Entertainment
Any other thing of value
0.00
$
$
$
SECTION D: Itemized Expenditures and Receptions
19. Itemize information from totals listed in Section D. If additional space is needed, attach FORM X – Itemized Lobbying Expenditures.
Recipient
Recipient’s Office Title
Date
Place
Provider
Item Description
Value/Cost
$
$
$
$
TOTAL, this page
0.00
$
X
Attached Form
20. Itemize information for all receptions as defined in §5-8-11 (7)(a), Miss. Code Ann. (1972).
If additional space is needed, attach FORM XP – Itemized Lobbying Receptions.
Date
Place/Location
Est. No. Public Officials
Est. Total Attendance
Total Reception Cost
$
$
$
$
0.00
TOTAL
$
, Reception Costs
XP
Attached Form
Notary Information
Lobbyist’s Client Signature
State of_____________________
Sworn and subscribed before
I certify that the above information is true and
correct, according to my knowledge, information
me this__________ day of
County of___________________
and belief.
______________________ , _________
Print name here
____________________________________
Notary Public
Signature
Date
My Commission expires
____________________________________
PENALTY NOTIFICATION: Miss. Code Ann. §5-8-21 (1972) provides that a conviction for violation of the lobbying law, for the first
offense, carries a penalty of a maximum of six (6) months in jail and a fine of One Thousand Dollars ($1,000); and for subsequent offenses a
maximum of three (3) years in the penitentiary and a fine of Five Thousand Dollars ($5,000).
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