Free Lobbyist Disclosure Statement (2007) - Virginia

Office of the Secretary of the Commonwealth Commonwealth of Virginia Lobbyist's Disclosure Statement (Rev. 5/07)

PART I: (1) PRINCIPAL:.................................................

In Part I, item 2a, provide the name of the individual authorizing your employment as a lobbyist. The lobbyist filing this statement MAY NOT list his name in item 2a. THE INDIVIDUAL LISTED IN PART I, ITEM 2A, MUST SIGN THE PRINCIPAL'S STATEMENT. (2a)Name:........................................................ (2b)Permanent Business Address:............................................ (2c)Business Telephone:.................................................... (3) Provide a list of executive and legislative actions (with as much specificity as possible) for which you lobbied and a description of activities conducted. ................................................................. ................................................................. ................................................................. (4) INCORPORATED FILINGS: If you are filing an incorporated disclosure statement, please complete the following: Individual filing financial information:..................................... Individuals to be included in the filing:.................................... ................................................................. (5) Please indicate which schedules will be attached to your disclosure statement: ] [Schedule A: Entertainment Expenses ] [Schedule B: Gifts ] [Schedule C: Other Expenses (6) EXPENDITURE TOTALS: a) b) c) d) e) f) g) h) i) ENTERTAINMENT......................................$.......... GIFTS..............................................$.......... OFFICE EXPENSES....................................$.......... COMMUNICATIONS.....................................$.......... PERSONAL LIVING AND TRAVEL EXPENSES................$.......... COMPENSATION OF LOBBYISTS..........................$.......... HONORARIA..........................................$.......... REGISTRATION COSTS.................................$.......... OTHER..............................................$..........

TOTAL.................................................$..........

PART II: (1a) NAME OF LOBBYIST:................................................ (1b) Permanent Business Address:............................................ (1c) Business Telephone:............................................... (2) As a lobbyist, you are (check one) [] EMPLOYED (on the payroll of the principal) [] RETAINED (not on the payroll of the principal, however compensated) [] NOT COMPENSATED (not compensated; expenses may be reimbursed) (3) List all lobbyists other than yourself who registered to represent your principal. ................................................................. ................................................................. ................................................................. (4) If you selected "EMPLOYED" as your answer to Part II, item 2, provide your job title. .................................................................

PLEASE NOTE: Some lobbyists are not individually compensated for lobbying activities. This may occur when several members of a firm represent a single principal. The principal, in turn, makes a single payment to the firm. If this describes your situation, do not answer Part II, items 5a and 5b. Instead, complete Part III, items 1 and 2. (5a) What was the DOLLAR AMOUNT OF YOUR COMPENSATION as a lobbyist? (If you have job responsibilities other than those involving lobbying, you may have to prorate to determine the part of your salary attributable to your lobbying activities.) Transfer your answer to this item to Part I, item 6f. (5b) Explain how you arrived at your answer to Part II, item 5a ................................................................. ................................................................. .................................................................

PART III: PLEASE NOTE: If you answered Part II, items 5a and 5b, you WILL NOT complete this section. (1) List all members of your firm, organization, association, corporation, or other entity who furnished lobbying services to your principal. ................................................................. ................................................................. ................................................................. (2) Indicate the total amount paid to your firm, organization, association, corporation or other entity for services rendered. Transfer your answer to this item to Part I, item 6f ........................................

SCHEDULE A ENTERTAINMENT EXPENSES PLEASE NOTE: Any single entertainment event included in the expense totals of the principal, with a value greater than $50, should be itemized below. Transfer any totals from this schedule to Part I, item 6a. (Please duplicate as needed.) Date and Location of Event: ................................................................. ................................................................. Description of Event: ................................................................. ................................................................. Total Number of Persons Attending: ................................................................. Names of Legislative and Executive Officials Attending: (List names only if the average value for each person attending the event was greater than $50.) ................................................................. ................................................................. ................................................................. ................................................................. Food.............................................$.......... Beverages........................................$.......... Transportation of Legislative and Executive Officials$.......... Lodging of Legislative and Executive Officials$.......... Performers, Speakers, Etc.....................$.......... Displays......................................$......... Rentals.......................................$.......... Service Personnel.............................$.......... Miscellaneous.................................$.......... TOTAL.........................................$ ..........

SCHEDULE B GIFTS PLEASE NOTE: Any single gift reported in the expense totals of the principal, with a value greater than $50, should be itemized below. (Report meals, entertainment and travel under Schedule A.) Transfer any totals from this schedule to Part I, item 6b. (Please duplicate as needed.) Date of gift: Description of gift: Name of each legislative or executive official who is a recipient of a gift ___________________ ___________________ ___________________ ___________________ Cost of individual gift

_______ _______ _______ _______

_______ _______ _______ _______

_________ _________ _________ _________

TOTAL COST TO PRINCIPAL...............................$..........

SCHEDULE C OTHER EXPENSES PLEASE NOTE: This section is provided for any lobbying-related expenses not covered in Part I, items 6a - 6h. An example of an expenditure to be listed on schedule C would be the rental of a bill box during the General Assembly session. Transfer the total from this schedule to Part I, item 6i. (Please duplicate as needed.)

DATE OF EXPENSE

DESCRIPTION OF EXPENSE

AMOUNT

.........................................................$....... .........................................................$....... .........................................................$....... .........................................................$....... .........................................................$....... TOTAL "OTHER" EXPENSES.................................$..........

PART IV: STATEMENTS Both the lobbyist and principal officer must sign the disclosure statement, attesting to its completeness and accuracy. The following items are mandatory and if they are not properly completed, the entire filing will be rejected and returned to the lobbyist: (1) All signatures on the statement must be ORIGINAL in the format specified in the instructions provided by the Secretary that accompany this form. No stamps, or other reproductions of the individual's signature will be accepted. (2) An individual MAY NOT sign the disclosure statement as lobbyist and principal officer.

STATEMENT OF LOBBYIST I, the undersigned registered lobbyist, do state that the information furnished on this disclosure statement and on all accompanying attachments required to be made thereto is, to the best of my knowledge and belief, complete and accurate. ................................................................. Signature of lobbyist ................................................................. Date

STATEMENT OF PRINCIPAL I, the undersigned principal (or an authorized official thereof), do state that the information furnished on this disclosure statement and on all accompanying attachments required to be made thereto is, to the best of my knowledge and belief, complete and accurate. ................................................................. Signature of principal ................................................................. Date