Lobbyist CertificationStatement FAIR POLITICAL PRACTICES COMM. CALIFORNIA FORM 604 The "Lobbyist Certification Statement" is used for: · Initialcertificationofanindividualwhoqualifiesas alobbyist,includinganindividualcontractlobbyist. (CommissionRegulation2Cal.CodeofRegs.Section 18239.) · Renewaloflobbyistcertification. Certification Requirements: · Lobbyists are required to complete Form 604 (Lobbyist Certification Statement) and provide a recentphotograph(headandshouldersonly). · The Form 604 must be filed with the Secretary of State as an attachment to one of the following: --yourlobbyingfirm'sregistration,Form601,or --yourlobbyistemployer/coalitionregistration, Form603,or --your firm's or employer's Amendment to Registration,Form605. Renewing a Registration: · Submita$100registrationfee($50peryear). New Registration: · The registration fee is $50 per year and when registeringinthefirstyearofthetwo-yearsessiona paymentof$100isrequired. · Lobbyistsarerequiredtoattendanethicsorientation courseconductedbytheLegislature.TheLegislature willnotifylobbyistsofcoursedates,andwillprovide acertificateofcompletionofthecourse.Ifthecourse hasnotbeencompletedwithintheprevious12months: --Newlobbyistsmusttakethecoursewithin12months afterqualifyingasalobbyist. --Lobbyistsrenewingtheircertificationsmusttake thecoursebyJune30ofthefollowingyear. The lobbyist certification is conditional until the course is taken. Failure to take the course at the timesspecifiedwillvoidaconditionalcertification. Oncevoided,anindividualisprohibitedfromacting asalobbyistuntilhe/shehascompletedthecourse andfiledanamendedlobbyistcertificationstatement indicatingthedatethecoursewastaken. --Lobbyistswhohavefiledaconditionalcertification statementmustfileanamendedForm604within20 daysfollowingcompletionofthecourse.Indicate thedateyoucompletedthecourseandfilewiththe SecretaryofState. Section86100requiresaregistrationstatementtobefiled onlineorelectronicallyandtheoriginalandonecopyin paperformatwith: SecretaryofState PoliticalReformDivision 150011thStreet P.O.Box1467 Sacramento,CA95812-1467 --Donotattachyourcertificateofcoursecompletion. Maintainthiscertificateinyourrecords. · 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 beregisteredtolobbyallagenciesidentifiedonthe Lobbyist Employer or Lobbying Firm Registration Statementandallsubsequentamendments. · Lobbyistsaresubjecttocertainrestrictionsoutlined onthereverseofForm604. Filing Deadlines: NewLobbyists: Within10daysofqualifyingasalobbyist. LobbyistsRenewingCertification: BetweenNovember1andDecember31ofeacheven- numberedyear. Amendment to Certification: Within20daysofanychangetotheinformationcontained ontheForm604(e.g.,changeofemployerorfirm)an amended Form 604 must be filed with the Secretary ofStateasanattachmenttoyouremployer'sorfirm's completedForm605(AmendmenttoRegistration). FPPC Form 604 (10/14) FPPC Advice Email: advice@fppc.ca.gov FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com Lobbyist Certification Statement (GovernmentCodeSection86103) Legislative Session FAIR POLITICAL PRACTICES COMM. CALIFORNIA FORM 604 ForOfficialUseOnly Type or Print in Ink CheckBoxifanAmendment NAMEOFLOBBYIST: (Last) (First) (InsertYears) (M.I.) IfthisisanInitialCertification,enter theDATEQUALIFIEDasaLobbyist: (ZipCode) TELEPHONENUMBER: ( MAILINGADDRESS:(Ifdifferentthanabove) ) BUSINESSADDRESS:(NumberandStreet) (City) (State) FAXNUMBER:(Optional) ( ) NAMEOFLOBBYISTEMPLOYERORLOBBYINGFIRM: E-MAIL: I. LOBBYIST ETHICS ORIENTATION COURSE Check one box: Ihavenottakenthecoursewithintheprevious12months.Iwillattendthecourse(check one): NewCertification­Withinthenext12months Renewal­ByJune30ofthenextcalendaryear Icompletedthecourseon II. AGENCIES LOBBIED Check one box: / / . (Mo./Day/Year) IwilllobbytheagenciesidentifiedontheLobbyistEmployerorLobbyingFirmRegistrationStatement(Form601/603) andsubsequentamendments. Iwillonlylobbytheagenciesidentifiedbelow: WillyoulobbytheStateLegislature? Yes No StateAgencies: III. LOBBYIST RESTRICTIONS Bysigningtheverificationbelow,IcertifythatIhavereadandunderstandthatIamsubjecttotheprohibitionscontainedin GovernmentCodeSections86203and86205. (Providedonreverse.) 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. Executedon By DATE FPPC Form 604 (10/14) FPPC Advice Email: advice@fppc.ca.gov FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com SIGNATUREOFLOBBYIST Lobbyist CertificationStatement FAIR POLITICAL PRACTICES COMM. CALIFORNIA FORM 604 Additional Information RefertotheLobbying Disclosure Information Manual foradditionalinformationandinformationrequiredto beprovidedtoyoupursuanttotheInformationPractices Actof1977. Government Code sections which restrict a lobbyist's abilitytomakegiftstocertainpublicofficialsareprovided below. Government Code Section 86203: Itshallbeunlawfulforalobbyist,oralobbyingfirm, tomakegiftstoonepersonaggregatingmorethanten dollars($10)inacalendarmonth,ortoactasanagent orintermediaryinthemakingofanygift,ortoarrange forthemakingofanygiftbyanyotherperson. "Gift" as used in Section 86203 means a gift made directlyorindirectlytoanystatecandidate,electedstate officer, or legislative official, or to an agency official ofanyagencyrequiredtobelistedontheregistration statementofthelobbyingfirmorthelobbyistemployer ofthelobbyist. Government Code Section 86205: Nolobbyistorlobbyingfirmshall: (a) Doanythingwiththepurposeofplacinganyelected stateofficer,legislativeofficial,agencyofficial,or state candidate under personal obligation to the lobbyist,thelobbyingfirm,orthelobbyist'sorthe firm'semployer. (b)Deceive or attempt to deceive any elected state officer,legislativeofficial,agencyofficial,orstate candidatewithregardtoanymaterialfactpertinentto anypendingorproposedlegislativeoradministrative action. (c) Cause or influence the introduction of any bill or amendmenttheretoforthepurposeofthereafterbeing employedtosecureitspassageordefeat. (d)Attempttocreateafictitiousappearanceofpublic favor or disfavor of any proposed legislative or administrativeactionortocauseanycommunication to be sent to