Form LRS (Rev. 12/10) Elaine F. Marshall, Secretary of State Lobbyist Resignation Statement 2011 Statement of Resignation I _________________________________________________hereby resign as a lobbyist for the principal (Print name of Lobbyist) ____________________________________________________________________________________, (Print name of Principal) and I understand that I must file an expense report for every required reporting period in which I was registered as a lobbyist including any required reporting period in which the lobbyist/principal relationship is severed. G.S. §120C-401(a). Questions about the file date for a termination or resignation should be referred to the Lobbying Compliance Division prior to the reporting deadline. __________________________________________________ Signature of Lobbyist __________________ Date The contact information on my registration statement has changed. As of __________________ my new contact information is: Telephone #: _______________________________ Fax #: _______________________________ Email address: ___________________________________________________________________ Mailing address: __________________________________________________________________ Preparer Information ________________________________________________________________________________ Signature of Preparer (If Other Than Lobbyist) Printed Name of Preparer American LegalNet, Inc. www.FormsWorkFlow.com