Form LRS Page 1 of 3 (Rev. 9/10) Elaine F. Marshall, Secretary of State Lobbyist Registration Statement 2010 Lobbyist Information Complete Name of Lobbyist:__________________________________________________________________ EFFECTIVE OCTOBER 1, 2010. Please answer the next two required questions. Please answer with the applicable answer: yes, no, or N/A on each line. _______I am a former public servant 1 and have been separated from employment as a public servant for more than 6 months. _______ I am a former employee of a State of North Carolina Agency and plan to lobby the state agency that previously employed me. My former state agency employer is: ________________________________. (Enter state agency name) Firm Name of Lobbyist (If Applicable):__________________________________________________________ 2 Check all applicable boxes: Lobbyist is not a member of a Firm Lobbyist is an employee of the Principal Business Address of Lobbyist (Physical NOT a P.O. Box):__________________________________________ Mailing Address of Lobbyist:__________________________________________________________________ Telephone No. of Lobbyist:_________________________________ Fax No.:__________________________ E-Mail Address of Lobbyist*:__________________________________________________________________ Optional secondary e-mail address (Example: Administrative Assistant): _______________________________ Principal Information Complete Name of Principal**:________________________________________________________________ Business Address of Principal (Physical):________________________________________________________ Name of Principal’s Authorized Officer:_________________________________________________________ Title of Principal’s Authorized Officer: _________________________________________________________ Mailing Address of Principal’s Authorized Officer:_________________________________________________ Telephone No. of Principal’s Authorized Officer:______________________ Fax No.:_____________________ E-Mail Address of Principal’s Authorized Officer *: ______________________________________________ Optional secondary e-mail address (Example: Administrative Assistant): _______________________________ Check if attaching form RW, Application for Waiver/Reduction of Registration Fees for 26 U.S.C. 501(c)(3). Note: see page 2 of RW form for fee amount. Registrations submitted without correct fee will be rejected. 1 2 A public servant is a legislator, legislative staff, or designated executive branch elected and appointed officials. You must check a box or complete the Firm Name Section above otherwise this registration will be rejected. American LegalNet, Inc. www.FormsWorkFlow.com Form LRS Page 2 of 3 (Rev. 9/10) General Subjects on Which the Lobbyist Intends to Lobby Enter codes from the subject identification table below. List all applicable categories. A statement of ALL will not be accepted. Registration will be rejected if catagory 31 “Other” is selected and no subject is specified. Code Subject Code 1 Agriculture, horticulture, farming, and livestock Amusements, games, athletics, sports, and entertainment Banking, finance, credit and investments Children, minors, youth, seniors Church and religion Communications, newspaper, television, radio, computers and information technology Consumer affairs Ecology, environment, pollution, conservation, zoning, land and water use Education Elections, campaigns, voting, political parties 17 27 28 13 14 15 Equal rights, civil rights, minority affairs Government, taxation, financing, revenue, budget, appropriations, bids, fees, funds Government, county Government, federal Government, municipal 16 Government, state 2 3 4 5 6 7 8 9 10 11 12 Subject 18 Health service, medicine, drugs and controlled substances, health insurance, hospitals Higher education 19 20 21 22 Housing, construction, building codes Insurance (excluding health insurance) Labor, salaries and wages, collective bargaining Law enforcement, courts, judges, crimes, prisons 23 24 Licenses, permits Liquor, alcoholic beverages 25 26 Manufacturing, distribution, services Natural resources, forest and forest products, fisheries, mining and mining products Public lands, parks, recreation Social insurance, unemployment insurance, public assistance, workers compensation Transportation, highways, streets and roads Utilities, power, cable television, gas Other (*must specify):________________________ ___________________________________________ 29 30 31 * The Division will send notices regarding filing due dates electronically at no charge. If you desire to receive notices from our office in another format, please indicate that by checking this box and you will be invoiced according to N.C.G.S. § 132-1(b). Certification I hereby certify that all information disclosed in this “Lobbyist Registration Statement 2010” is true, complete and correct in accordance with N.C.G.S. §120C-200. By signing this certification, I understand I have an affirmative duty to comply with the Lobbying Law and to understand the rules, including filing reports as the law requires. ________________________________________________________ Signature of Lobbyist _______________________________ Date Report Preparer’s Identity/Signature (Rule 18 NCAC 12.0209) Print name of Preparer (if other than lobbyist) ____________________________________________________________ Signature of Preparer__________________________________________________________ Date ________________ American LegalNet, Inc. www.FormsWorkFlow.com Form LRS Page 3 of 3 (Rev. 9/10) * 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 these avenues. ** The person or governmental unit on whose behalf the lobbyist lobbies and who makes payment for the lobbying. In the case where a lobbyist is paid by a law firm, consulting firm, or other entity retained by a person or governmental unit for lobbying, the principal is the person or governmental unit whose interests the lobbyist represents in lobbying. In the case of a lobbyist employed or retained by an association or other organization, the lobbyist principal is the association or other organization, not the individual members of the association or other organization. (Form PR-RS/LA). Registration will expire on January 1 of the following year unless written notification of termination or resignation is received prior to that date. The lobbyist shall file a new registration statement for each year. The fee of one hundred dollars ($100.00) is due and payable to the Secretary of State at the time of each lobbyist registration, N.C.G.S. § 120C-201(a). Note: Registration must take place within one day of lobbying. FILING SUBMISSION LOCATIONS AND METHODS Each required filing shall be submitted to the Department by one of the following methods: (1) By United States mail at the following address: Lobbying Compliance Division Department of the Secretary of State P. O. Box 29622 Raleigh, N.C. 27626-0622 (2) By hand-delivery or by a designated delivery service authorized pursuant to G.S. 1A-1, Rule 4 at the following street address: Lobbying ComplianceDivision Department of the Secretary of State 2 South Salisbury Street Raleigh, N.C. 27601-2903 (3) Electronically by electronic mail via the Internet site at the following address: lobbyistfiling@sosnc.com. Any document(s) attached to the filing other than the form or report shall be compatible with or convertible to the most recently issued version of Microsoft Word®; (4) By facsimile (919-807-2205) for filings not requiring a fee, provided the original signed document is postmarked or delivered to the Department within seven days following the Department's receipt of the faxed transmission. A filing for which the original is not postmarked or delivered to the Department within seven days following the Department's receipt of the faxed transmission is void. A document received by hand-delivery or fax after 5:00 p.m. is considered to be received on the following day. For each quarter a lobbyist is registered, he or she is obligated to file a quarterly expense report and may be obligated to file monthly expense reports when necessary. For further explanation of regulations and guidelines, see Lobbying Guidelines -- General Information (Form LR-GI) NOTE: REGISTRATION TRIGGERS REPORTING OBLIGATIONS. QUARTERLY REPORTS MUST BE FILED REGARDLESS OF WHETHER THERE ARE ANY REPORTABLE EXPENDITURES. DO NOT USE THIS FORM IF YOU ARE REGISTERING FOR ECONOMIC INFORMATION PROTECTION. American LegalNet, Inc. www.FormsWorkFlow.com