(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. 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. a)ENTERTAINMENT…………………………………………$ ………b)GIFTS………………………………………………..$ ………c)COMMUNICATIONS………………………………………..$ ………d)PERSONAL LIVING AND TRAVEL EXPENSES……………………..$ ………e)COMPENSATION OF LOBBYISTS………………………………$ ………f)HONORARIA…………………………………………….$ ………g)OTHER………………………………………………..$ ………TOTAL………………………………………………….$ ………

(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 6e.

(5b. Explain how you arrived at your answer to Part II, item 5a……………………………………………………………..……………………………………………………………….……………………………………………………………….…

(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 6e.

SCH. ENTERTAINMENT EXPENSESPLEASE 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 (including whether or not it meets the criteria of a widely attended event):………………………………………………………………..…………………………………………………………………..…Total Number of Persons Attending:………………………………………………………………..…Names of Legislative and Executive Officials or Members of Their Immediate Families Attending: (List names only if the average value for each person attending the event was greater than $ 50.)………………………………………………………………..…………………………………………………………………..…………………………………………………………………..…………………………………………………………………..…Food$ ………Beverages$ ………Immediate Families$ ………Families$ ………Performers, Speakers, Etc.$ ………Displays$ ………Rentals$ ………Service Personnel$ ………Miscellaneous$ ………TOTAL$ ………

GIFTSPLEASE 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.)Name of eachlegislative orexecutive officialor member of hisimmediate family Cost ofDate Description who is a recipient individualof gift: of gift: of a gift: gift:….………..…………………$ ………….………..…………………$ ………….………..…………………$ ………….………..…………………$ ………TOTAL COST TO PRINCIPAL …………………$ ………

OTHER EXPENSESPLEASE NOTE: This section is provided for any lobbying-related expenses not covered in Part I, items 6a — 6f. 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 6g. (Please duplicate as needed.)DATE OF EXPENSE DESCRIPTION OF EXPENSE AMOUNT………………………………………………………..$………….…………………………………………………………..$………….…………………………………………………………..$………….…………………………………………………………..$………….…………………………………………………………..$………….…………………………………………………………..$………….…………………………………………………………..$………….…………………………………………………………..$………….…………………………………………………………..$………….…TOTAL “OTHER ” EXPENSES ………………………….…$………..…

(1. All signatures on the statement must be ORIGINAL in the format specified in the instructions provided by the Council 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 LOBBYISTI, 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………………………………..…DateSTATEMENT 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

C. The report shall be on a form prescribed by the Council and shall be accompanied by instructions provided by the Council. All reports shall be submitted electronically and in accordance with the standards approved by the Council pursuant to the provisions of § 30-356.

D. A person who knowingly and intentionally makes a false statement of a material fact on the disclosure statement is guilty of a Class 5 felony.

E. The name of a legislative or executive official, or a member of his immediate family, attending any reportable entertainment event shall not be required to be disclosed by the principal if that legislative or executive official reimburses the principal for, or otherwise pays for, his attendance, or the attendance of a member of his immediate family, at the entertainment event. Reimbursement shall be calculated using the average value for each person attending the event.

F. Each lobbyist shall send to each legislative and executive official who is required to be identified by name on Schedule A or B of the Lobbyist’s Disclosure Form a copy of Schedule A or B or a summary of the information pertaining to that official. Copies or summaries shall be provided to the official by December 15 for the preceding 12-month period complete through November 30.