County of Los Angeles INSTRUCTIONS FOR LOBBYIST CERTIFICATION STATEMENT FORM LOB 4 Chapter 2.160 of the Los Angeles County Code The Lobbyist Certification Statement is used for: · · Certification of an individual contract lobbyist or owner (including sole-proprietor), partner, officer or employee of a lobbying firm who qualifies as a lobbyist. Certification of an in-house employee of a lobbyist employer who qualifies as a lobbyist. CERTIFICATION REQUIREMENTS: · Each individual contract lobbyist and each employee of a lobbying firm who qualifies as a lobbyist is required to complete the Lobbyist Certification Statement (Form LOB 4) as an attachment to the Lobbying Firm/ Individual Lobbyist Registration Statement (Form LOB 1) and provide a recent 3x4 inch photograph (head and shoulders only). Each in-house employee of a lobbyist employer who qualifies as a lobbyist is required to complete a Lobbyist Certification Statement (Form LOB 4) as an attachment to the Lobbyist Employer Registration Statement (Form LOB 3) and provide a recent 3x4 inch photograph (head and shoulders only). A $450 registration fee, made payable to the County of Los Angeles, is required if registration is filed between January 1st and September 30th. If registration is filed between October 1st and December 31st, the cost of registration is $337. · · FILING DEADLINE: · Registration forms, including the Lobbyist Certification Statement (Form LOB 4) must be filed within (10) days of qualifying as a lobbyist. AMENDMENT TO CERTIFICATION: · Within ten (10) days of any change to the information contained on the Lobbyist Certification Statement (Form LOB 4) (e.g., change of employer or firm name change) an Amendment to Registration Statement (Form LOB 5) must be filed. FILE THIS FORM WITH ORIGINAL SIGNATURE WITH THE: 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 INTERNET ACCESS The Los Angeles County Lobbyist Ordinance, rules, operational procedures, registration/reporting forms, and information on registrants and their quarterly activity reports are accessible at: Rev. 1/11 http://bos.co.la.ca.us/ American LegalNet, Inc. www.FormsWorkFlow.com OFFICIAL USE ONLY COUNTY OF LOS ANGELES Lobbyist Certification Statement Form LOB 4 Enter Date Qualified as a Lobbyist: Lobbyist Name: Business Address: City: Mailing Address: (If different than Business Address) City: Area Code & Telephone Number: (No Dashes) State: State: E-Mail Address: Zip Code: Zip Code: Extension: Area Code & Fax Number: (No Dashes) ATTACH PHOTO 3x4 REQUIRED VERIFICATION (head & shoulders only) BY SIGNING THE VERIFICATIONS BELOW, I CERTIFY THAT I HAVE READ AND UNDERSTAND THAT I AM SUBJECT TO THE PROHIBITIONS CONTAINED IN SECTIONS 2.160.120, 2.160.130 AND 2.190.130 OF THE LOS ANGELES COUNTY CODE. I have used all reasonable diligence in preparing this Statement. I have reviewed this Statement and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Executed On: City: State: Lobbyist Signature American LegalNet, Inc. www.FormsWorkFlow.com