CALIFORNIA FORM Lobbyist Certification Statement The “Lobbyist Certification Statement” is used for: • Initial certification of an individual who qualifies as a lobbyist, including an individual contract lobbyist. (Commission Regulation 2 Cal. Code of Regs. Section 18239.) Indicate the date you completed the course and file with the Secretary of State. File an original and one copy of this form with: Secretary of State Political Reform Division 1500 11th Street P.O. Box 1467 Sacramento, CA 95812-1467 • Renewal of lobbyist certification. Certification Requirements: • Lobbyists are required to complete Form 604 (Lobbyist Certification Statement) and provide a recent photograph (head and shoulders only). • The Form 604 must be filed with the Secretary of State as an attachment to one of the following: -- your lobbying firm’s registration, Form 601, or -- your lobbyist employer/coalition registration, Form 603, or -- your firm’s or employer’s Amendment to Registration, Form 605. • A $25 registration fee payable to the Secretary of State is required at the time of filing • Lobbyists are required to attend an ethics orientation course conducted by the Legislature. The Legislature will notify lobbyists of course dates, and will provide a certificate of completion of the course. If the course has not been completed within the previous 12 months: -- New lobbyists must take the course within 12 months after qualifying as a lobbyist. 604 FAIR POLITICAL PRACTICES COMM. -- Do not attach your certificate of course completion. Maintain this certificate in your records. • A lobbyist may list the agencies he/she lobbies on Form 604. (If more space is needed, include an attachment.) If none are listed, the lobbyist will be registered to lobby all agencies identified on the Lobbyist Employer or Lobbying Firm Registration Statement and all subsequent amendments. • Lobbyists are subject to certain restrictions outlined on the reverse of Form 604. Filing Deadlines: New Lobbyists: Within 10 days of qualifying as a lobbyist. Lobbyists Renewing Certification: Between November 1 and December 31 of each evennumbered year. -- Lobbyists renewing their certifications must take the course by June 30 of the following year. The lobbyist certification is conditional until the course is taken. Failure to take the course at the times specified will void a conditional certification. Once voided, an individual is prohibited from acting as a lobbyist until he/she has completed the course and filed an amended lobbyist certification statement indicating the date the course was taken. Amendment to Certification: Within 20 days of any change to the information contained on the Form 604 (e.g., change of employer or firm) an amended Form 604 must be filed with the Secretary of State as an attachment to your employer’s or firm’s completed Form 605 (Amendment to Registration). Additional Information -- Lobbyists who have filed a conditional certification statement must file an amended Form 604 within 20 days following completion of the course. Refer to the Lobbying Disclosure Information Manual for additional information and information required to be provided to you pursuant to the Information Practices Act of 1977. FPPC Form 604 (7/98) For Technical Assistance: 916/322-5660 American LegalNet, Inc. www.FormsWorkFlow.com h:\lobbying\forms\1998\604 Lobbyist Certification Statement Legislative Session CALIFORNIA FORM 604 FAIR POLITICAL PRACTICES COMM. (Government Code Section 86103) For Official Use Only Type or Print in Ink (Insert Years) Check Box if an Amendment NAME OF LOBBYIST: (Last) (First) (State) (City) BUSINESS ADDRESS: (Number and Street) If this is an Initial Certification, enter the DATE QUALIFIED as a Lobbyist: (M.I.) (Zip Code) TELEPHONE NUMBER: ( MAILING ADDRESS: (If different than above) ) FAX NUMBER: (Optional) ( NAME OF LOBBYIST EMPLOYER OR LOBBYING FIRM: ) E-MAIL: (Optional) I. LOBBYIST ETHICS ORIENTATION COURSE Check one box: I have not taken the course within the previous 12 months. I will attend the course (check one): New Certification – Within the next 12 months Renewal – By June 30 of the next calendar year I completed the course on / / . (Mo./Day/Year) II. AGENCIES LOBBIED Check one box: I will lobby the agencies identified on the Lobbyist Employer or Lobbying Firm Registration Statement (Form 601/603) and subsequent amendments. I will only lobby the agencies identified below: Will you lobby the State Legislature? Yes No State Agencies: III. LOBBYIST RESTRICTIONS By signing the verification below, I certify that I have read and understand that I am subject to the prohibitions contained in Government Code Sections 86203 and 86205. (Provided on reverse.) VERIFICATION 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. Executed on By DATE SIGNATURE OF LOBBYIST American LegalNet, Inc. www.FormsWorkFlow.com Lobbyist Certification Statement CALIFORNIA FORM 604 FAIR POLITICAL PRACTICES COMM. Government Code sections which restrict a lobbyist’s ability to make gifts to certain public officials are provided below. Government Code Section 86203: It shall be unlawful for a lobbyist, or a lobbying firm, to make gifts to one person aggregating more than ten dollars ($10) in a calendar month, or to act as an agent or intermediary in the making of any gift, or to arrange for the making of any gift by any other person. “Gift” as used in Section 86203 means a gift made directly or indirectly to any state candidate, elected state officer, or legislative official, or to an agency official of any agency required to be listed on the registration statement of the lobbying firm or the lobbyist employer of the lobbyist. (d) Attempt to create a fictitious appearance of public favor or disfavor of any proposed legislative or administrative action or to cause any communication to be sent to any elected state officer, legislative official, agency official, or state candidate in the name of any fictitious person or in the name of any real person, except with the consent of such real person. (e) Represent falsely, either directly or indirectly, that the lobbyist or the lobbying firm can control the official action of any elected state officer, legislative official, or agency official. (f) Accept or agree to accept any payment in any way contingent upon the defeat, enactment, or outcome of any proposed legislative or administrative action. Government Code Section 86205: No lobbyist or lobbying firm shall: (a) Do anything with the purpose of placing any elected state officer, legislative official, agency official, or state candidate under personal obligation to the lobbyist, the lobbying firm, or the lobbyist’s or the firm’s employer. (b) Deceive or attempt to deceive any elected state officer, legislative official, agency official, or state candidate with regard to any material fact pertinent to any pending or proposed legislative or administrative action. (c) Cause or influence the introduction of any bill or amendment thereto for the purpose of thereafter being employed to secure its passage or defeat. FPPC Form 604 (7/98) For Technical Assistance: 916/322-5660 American LegalNet, Inc. www.FormsWorkFlow.com