County of Los Angeles INSTRUCTIONS FOR REQUEST FOR WAIVER OF LIABILITY FORM LOB 11 County Code Chapter 2.160 A REQUEST FOR WAIVER OF LIABILITY (Form LOB 11) is used to request waiver of a late fee or fine imposed for the failure to comply with Chapter 2.160 of the Los Angeles County Code (the Lobbyist Ordinance.) There are two categories of "good cause" for waiving late filing fees or fines. These causes must relate to the person required to file the statements or reports. FIRST CATEGORY OF GOOD CAUSE: 1. Incapacitation for Medical Reasons - Adequate documentation consists of statement by a doctor, psychologist, therapist, chiropractor, or other medical provider giving the nature of the incapacitation, the date(s) thereof, and the individual's name. 2. Hospitalization - Adequate documentation consists of a copy of the hospital bill or doctor's statement showing the patient's name and the date(s) of the hospitalization. 3. Accident Involvement - If medical attention is provided and results in the late filing, a copy of the hospital bill, emergency room service, or doctor's statement, showing the patient's name and date(s) and time(s) of medical attention, is adequate documentation. If the accident involvement results in delay or vehicle disablement which causes the late filing, adequate documentation consists of a police report showing the individual's name, the date and time of the accident, and, if applicable, whether or not the vehicle was disabled. 4. Death - Adequate documentation consists of a copy of the death certificate or an obituary notice. SECOND CATEGORY OF GOOD CAUSE: The second category is defined as other unique, unintentional factors beyond the filer's control not stemming from a negligent act or non action. The factors are: 1. Loss or Unavailability of Records - If the loss or unavailability of records was due to a fire, flood, theft or similar reason. Adequate documentation shall consist of a police, fire or insurance report, containing the date of the occurrence and the extent of the loss or damage. 2. Unique Reasons - If there were unique compelling reasons beyond the filer's control. IMPORTANT: The following examples are not legitimate reasons for reducing or waving late filing fines: · · · · · · The filer was not aware of the Ordinance or its requirements. The filer did not receive notice of the filing requirements. The filer incorrectly addressed the filing. The filer did not know where to obtain blank forms. The filer did not have complete information by the filing deadline. The filer did not receive or read his or her mail in a timely manner. INTERNET ACCESS Executive Officer of the Board of Supervisors County of Los Angeles Kenneth Hahn Hall of Administration 500 W. Temple Street, Room 383 Los Angeles, California 90012 (213) 974-1093 Rev. 1/11 The Los Angeles County Lobbyist Ordinance, rules, operational procedures, registration/ reporting forms, and information on registrants and their quarterly activity reports are accessible at: http://bos.co.la.ca.us/ American LegalNet, Inc. www.FormsWorkFlow.com FILE THIS FORM WITH ORIGINAL SIGNATURE WITH THE: OFFICIAL USE ONLY COUNTY OF LOS ANGELES REQUEST FOR WAIVER OF LIABILITY Form LOB 11 Type or Print in Ink Lobbying Firm Lobbyist Employer/Client Lobbyist Name of Firm, Employer/Client or Lobbyist: Address: City: Area Code & Telephone Number: (No Dashes) State Extension: Zip Code: Area Code & Fax Number: (No Dashes) AFTER REVIEWING "GOOD CAUSE" WAIVER RESTRICTIONS, IDENTIFY AND EXPLAIN THE REASON FOR LATE FILING AND INCLUDE SUPPORTING DOCUMENTATION (See Attachments): (Continue on next page, if needed) I declare and certify under penalty of perjury that the foregoing information on this request for waiver is true and correct. I hereby request that the liability for failing to file the statement or report on time as required by the Los Angeles County Code, Chapter 2.160 (Lobbyist Ordinance) be waived. Date Executed On Name of Filer: Signature of Filer: City: State: Print Form American LegalNet, Inc. www.FormsWorkFlow.com AFTER REVIEWING "GOOD CAUSE" WAIVER RESTRICTIONS, IDENTIFY AND EXPLAIN REASON FOR LATE FILING AND INCLUDE SUPPORTING DOCUMENTATION (Continued): FOR OFFICIAL USE ONLY Period Covered: Form No.: Date Due: Date Filed: Liability: WAIVER ACTION Waiver Granted Fine Reduced Waiver Denied Notes: American LegalNet, Inc. www.FormsWorkFlow.com