Form LLR-SAS, Page 1 of 4 (Rev. 12/4/2017) Elaine F. Marshall, Secretary of State Liaison Registration and State Agency Authorization Statement 2018 NO REGISTRATION FEE REQUIRED Liaison Personnel Information Complete Name of Liaison: Complete Name of State Agency, Board or Commission: Physical Business Address of Liaison Mailing Address of Liaison: Telephone No. of Liaison: Fax No.: E-mail Address of Liaison: State Agency Information Complete Name of State Agency*: Physical Address of State Agency: Complete Name of Contact Person: Title: Mailing Address of Contact Person: Telephone No. of Contact Person: Fax No.: E-Mail Address of Contact Person: * State Agency includes all agencies and constitutional officers of the State, including all boards, departments, divisions, constituent institutions of The University of North Carolina, and other units of government in the executive branch, on whose behalf the liaison influences or attempts to influence legislative and/or executive action. Both Liaison and State Agency Contact Person must sign certification. American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAS, Page 2 of 4 (Rev. 12/4/2017) GENERAL SUBJECTS ON WHICH THE LIAISON INTENDS TO LOBBY Enter codes from the subject identification table below. List all applicable categories. A statement of ALL will not be accepted. Code Subject Code Subject 1 Agriculture, horticulture, farming, and livestock 17 Health service, medicine, drugs and controlled substances, health insurance, hospitals 2 Amusements, games, athletics and sports 18 Higher education 3 Banking, finance, credit and investments 19 Housing, construction, building codes 4 Children, minors, youth, seniors 20 Insurance (excluding health insurance) 5 Church and religion 21 Labor, salaries and wages, collective bargaining 6 Communications, newspaper, television, radio, computers and information technology 22 Law enforcement, courts, judges, crimes, prisons 7 Consumer affairs 23 Licenses, permits 8 Ecology, environment, pollution, conservation, zoning, land and water use 24 Liquor, alcoholic beverages 9 Education 25 Manufacturing, distribution, services 10 Elections, campaigns, voting, political parties 26 Natural resources, forest and forest products, fisheries, mining and mining products 11 Equal rights, civil rights, minority affairs 27 Public lands, parks, recreation 12 Government, taxation, financing, revenue, budget, appropriations, bids, fees, funds 28 Social insurance, unemployment insurance, public assistance, workers compensation 13 Government, county 29 Transportation, highways, streets and roads 14 Government, federal 30 Utilities, power, cable television, gas 15 Government, municipal 31 * Other : ( please specify ) 16 Government, state *Registration will be rejected if category . Print name of Preparer (if other than lobbyist): Signature of Preparer: Date American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAS, Page 3 of 4 (Rev. 12/4/2017) Liaison and State Agency Contact Person Certification LIAISON CERTIFICATION I hereby certify that all informatioLiaison Registration and State Agency Authorization Statement 2018accordance with Article 2 of Chapter 120C. By signing this certification, I understand I have an affirmative duty to comply with the Lobbying Law and the rules, including filing reports, as the law requires. SIGNATURE OF LIAISON DATE STATE AGENCY AUTHORIZATION CERTIFICATION ncy Authorization Statement 2018certification, I understand I have an affirmative duty to comply with the Lobbying Law and the rules, including filing reports as the law requires. SIGNATURE OF STATE AGENCY CONTACT PERSON DATE American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAS, Page 4 of 4 (Rev. 12/4/2017) Instructions 1. Registration triggers reporting obligations. Quarterly reports must be filed regardless of whether you have any reportable expenditures. 2. Registration will expire on December 31 of the current year unless written notification of termination or resignation is received prior to that date. The liaison and state agency shall file a new registration statement for each year. No registration fee is required. Note: Registration must take place within one day of lobbying. 3. A liaison is any State employee, counsel employed under G.S. 247147-17, or officer whose principal duties, in practice or as set forth in that individual's job description, include lobbying legislators or legislative employees. G.S. 247120C-100 (a) (8). 4. If you do not provide an email address on this form and do not mark the box to receive notices in another format (page 2 of this document), we are under no obligation to inform you of report due dates, form changes, or any other information we provide via electronic methods. 5. On October 1, 2013, legislatively mandated electronic filing became effective for lobbying registrations, reports, and their respective amendments. For more background on this change see: Section 27.1 of Session Law 2013-360, Senate Bill # 402. 6. FILING SUBMISSION: How to e-file your Liaison Registration: E-file by using the Lobbying Compliance Division Portal on our website https://www.sosnc.gov/ . Please send the hard copy to the Department within seven days or your registration will be void. American LegalNet, Inc. www.FormsWorkFlow.com