Form PTS (Rev. 12/10) Elaine F. Marshall, Secretary of State Principal Termination Statement 2011 Statement of Termination I hereby terminate the authorization of _________________________ to act as a lobbyist on behalf of (Print name of Lobbyist) ______________________________________________________and understand I, as the authorized (Print name of Principal) officer for the above named Principal, must file a Principal expense report for every required reporting period 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 Authorized Officer) _____________________ (Date) In the event we need to contact the above named lobbyist, please provide us with his/her most current contact information. Telephone #: _______________________________ Fax #: _______________________________ Email address: ____________________________________________________________________ Mailing address: __________________________________________________________________ Preparer Information Signature of Preparer Preparer (If Other Than Authorized Officer) Printed Name of American LegalNet, Inc. www.FormsWorkFlow.com