Form 615 Lobbyist Report Form. This is a California form and can be use in Fair Political Practices Commission Statewide.
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1990 FORM 615 LOBBYIST REPORT Every lobbyist must complete the “Lobbyist Report” (Form 615) for each calendar quarter, regardless of the level of activity of the lobbyist, and whether or not the lobbyist has made any payments during the quarter. Note: An individual contract lobbyist also must file reports as a lobbying firm. If you are registered as a lobbying firm, or are a partner, owner, or employee of a lobbying firm, your completed Form 615 must be attached to the firm’s quarterly report (Form 625). If you are an inhouse employee lobbyist who is not registered as a lobbying firm, your completed Form 615 must be attached to your employer’s quarterly report (Form 635). The periods covered and the filing deadlines for the “Lobbyist Report” are as follows: PERIOD COVERED January, February, and March April, May, and June July, August, and September October, November, and December FILING DEADLINE April 30 July 31 October 31 January 31 If a report is sent by first class mail, it is considered received on the date of postmark. Filing deadlines which fall on a Saturday, Sunday, or official state holiday are extended to the next regular business day. IMPORTANT: Except as noted above, there are no provisions in the Political Reform Act for extensions of the filing deadlines. A person who files after the deadline is liable for a fine of $10 per day until the report is filed. Instructions for completing the report are on the back of page 1. 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 REFER TO THE INFORMATION MANUAL ON LOBBYING DISCLOSURE PROVISIONS OF THE POLITICAL REFORM ACT FOR FURTHER INFORMATION. FOR ASSISTANCE, CALL 916/322-5660. American LegalNet, Inc. www.FormsWorkflow.com LOBBYIST REPORT OF PAGE (Government Code Section 86113) REPORT COVERS PERIOD FROM FORM 615 1990 THROUGH IMPORTANT: This report is to be completed by the lobbyist and attached to the Report of Lobbying Firm (Form 625) or Report of Lobbyist Employer/Report of Lobbying Coalition (Form 635), whichever is applicable. FOR OFFICIAL USE ONLY A TYPE OR PRINT IN INK For information required to be provided to you pursuant to the Information Practices Act of 1977, see Information Manual on Lobbying Disclosure Provisions of the Political Reform Act. NAME: (M.I.) (First) (Last) B NAME OF FIRM, EMPLOYER, OR COALITION: (State) (City) BUSINESS ADDRESS: (Number and Street) (Zip Code) TELEPHONE NUMBER: ( ) MAILING ADDRESS: (If different than above) (See definitions and instructions PART I - ACTIVITY EXPENSES PAID, INCURRED, ARRANGED OR PROVIDED BY THE LOBBYIST ( on reverse.) I have reviewed the form and instructions for reporting Activity Expenses and I have nothing to report. Date Name and Official Position of Reportable Persons and Amount Benefiting Each Name and Address of Payee Description of Consideration $ Total Amount of Activity $ If more space is needed, check box and attach continuation sheets (See instructions on reverse.) PART II - CAMPAIGN CONTRIBUTIONS MADE OR DELIVERED ( I have reviewed the form and instructions for reporting Campaign Contributions Made or Delivered and: I have nothing to report. Part II has been completed and is attached. VERIFICATION I have used all reasonable diligence in preparing this Report. I have reviewed the Report and to the best of my knowledge the information contained herein and in the attached schedules is true and complete. C D E I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. EXECUTED ON (DATE) AT (CITY AND STATE) BY (SIGNATURE OF LOBBYIST) F American LegalNet, Inc. www.FormsWorkflow.com LOBBYIST REPORT (FORM 615) INSTRUCTIONS FOR COMPLETING PAGE 1 NAME OF FIRM, EMPLOYER OR COALITION: If you are registered as a lobbying firm, or you are a partner, owner, or employee of a lobbying firm, provide the name of the firm as contained on the firm’s registration statement (Form 601). If you are an in-house employee lobbyist, enter the name of your employer as contained on the employer’s registration statement (Form 603). PERIOD COVERED BY REPORT: The period covered is the calendar quarter. (See the cover sheet of this form for period covered.) PART I -- ACTIVITY EXPENSES: An “activity expense” is any expense incurred or payment made which benefits in whole or in part any elective state official, legislative official, agency official, state candidate, or a member of the immediate family of one of these individuals. Activity expenses include gifts, honoraria, consulting fees, salaries, and any other form of compensation but do not include campaign contributions. An “agency official” is any official of a state agency whose administrative actions you have attempted or are attempting to influence. You must itemize all "activity expenses" arranged, incurred or paid by you, and you must report activity expenses during the period in which they occurred regardless of whether they were actually paid during the period. IMPORTANT: See the Information Manual on Lobbying Disclosure Provisions of the Political Reform Act for discussion and examples of “arranging” a gift. • If you have not paid, incurred, or arranged any activity expenses during the period, check the box to indicate that you have nothing to report. • If you have paid, incurred, or arranged any activity expenses: Date: Enter the date the expense was incurred or the event occurred. Name and Address of Payee: List the name and address of the vendor or other person to whom payment was made or incurred. If charged on a credit card, you must list the name of the credit card company and also the name of the vendor which received the payment. Name and Official Position of Reportable Persons and Amount Benefiting Each: List the name and official position, if any, of each reportable person who benefited from the payment. Also list the portion of the total activity expense which is attributable to each reportable person. Note: You are not required to list in this section yourself or any other person who benefited who is not a reportable person. You must, however, maintain in your records the total number of persons who benefited. Description of Consideration: Describe the goods or services received by the reportable person(s), e.g., lunch, drinks, flowers, etc. Total Amount of Activity: Enter the total amount paid, arranged, or incurred for the activity, not just the amount which benefited reportable persons. Regardless of the number of beneficiaries listed for a single payment, enter the payment in the “Total Amount of Activity” column only once. PART II -- CAMPAIGN CONTRIBUTIONS MADE OR DELIVERED: Check the applicable box and, if you have made any campaign contributions of $100 or more to state candidates, elected state officers, their controlled committees, or committees primarily formed to support such an officer or candidate, or personally delivered any contributions of $100 or more to state candidates or elected state officers, complete and attach Part II. REFER TO THE INFORMATION MANUAL ON LOBBYING DISCLOSURE PROVISIONS OF THE POLITICAL REFORM ACT FOR FURTHER INFORMATION. FOR ASSISTANCE, CALL 916/322-5660. American LegalNet, Inc. www.FormsWorkflow.com CONTINUATION SHEET FOR PAGE 1 ACTIVITY EXPENSES PAGE OF LOBBYIST REPORT (FORM 615) PERIOD COVERED: NAME OF LOBBYIST: (Continued) PART I - ACTIVITY EXPENSES ( Date Name and Address of Payee Name and Official Position of Reportable Persons and Amount Benefiting Each Description of Consideration $ Total Amount of Activity $ If more space is needed, check box and attach continuation sheets American LegalNet, Inc. www.FormsWorkflow.com OF PAGE PERIOD COVERED: NAME OF LOBBYIST: PART II - CAMPAIGN CONTRIBUTIONS MADE OR DELIVERED Disclose all monetary and non-monetary campaign contributions of $100 or more made from your personal funds during the quarter, or from a separate account under your control, to state candidates, elected state officers, their controlled committees, or committees primarily formed to support such officers or candidates, or delivered in person by you to state candidates or elected state officers. Date Name of Contributor (If other than Lobbyist) Name of Separate Account (If applicable) Name of Recipient (If Committee, also enter I.D. Number) Amount $ NOTE: Disclosure in this report does not relieve a filer of any obligation to file campaign disclosure statements required by Gov. Code Section 84200, et seq. American LegalNet, Inc. www.FormsWorkflow.com