Form A - Lobbyist'S Annual Report - Mississippi Secretary Of State
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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 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
General Information
th
ORIGINAL Report (report due on January 30
for the previous year’s activity)
1.
Certificate
2.
Cycle Year
3.
Type of
Number
Report
AMENDED Report (report returned to filer for corrections or signature)
TERMINATING Report (for filers terminating activity prior to December 31)
SECTION A: Identification
4.
Full name of person employed as a LOBBYIST
5.
PERMANENT mailing address of LOBBYIST
City
State
Zip
6.
Permanent Phone
7.
Fax
8.
E-mail/Other Phone
(
)
(
)
9.
Full Name of Lobbyist’s Client
SECTION B: Lobbyist’s Compensation
Disclose amount of compensation for each category.
10. Fee
11. Salary
12. Retainer
13. Reimbursement
14. Other
TOTAL
15.
,
SECTION B
$
$
$
$
$
0.00
$
Description of other
compensation from Item 14:
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