Form SR-RS Page 1 of 2 (Rev. 12/09) Elaine F. Marshall, Secretary of State Solicitor Registration Statement 2010 NO REGISTRATION FEE REQUIRED Solicitor Information Complete Name of Solicitor: __________________________________________________________________ Complete Name of Firm or Organization of Solicitor (If Applicable): __________________________________ _________________________________________________________________________________________ Complete Name and Title of Authorized Representative of Solicitor: __________________________________ Mailing Address of Authorized Representative of Solicitor: _________________________________________ _________________________________________________________________________________________ Physical Address of Authorized Representative of Solicitor: ________________________________________ _________________________________________________________________________________________ Weekday Telephone for Authorized Representative of Solicitor: _____________________________________ Fax No.: ____________________________ E-Mail Address: ______________________________________ ________________________________________________________________ Signature of Representative Authorized to Sign for Solicitor ________________________________________________________________ Name & Title of Representative Authorized to Sign for Solicitor _______________________ Date _______________________ Date 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 the 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 “Solicitor Registration Statement 2010” is true, complete and correct in accordance with N.C.G.S. §120C-215. By signing this certification, I understand I have an affirmative duty to understand the rules and to comply with the Lobbying Law, including filing reports as the law requires. __________________________________________________________________________________________ DATE SIGNATURE OF PERSON AUTHORIZED TO SIGN FOR SOLICITOR American LegalNet, Inc. www.FormsWorkFlow.com Form SR-RS Page 2 of 2 (Rev. 12/09) You may be a solicitor if you use any of the methods listed in the law (N.C.G.S. §120C-100(13)) to ask members of the public to contact a designated individual(s) for the purpose of influencing legislative or executive action or attempting to influence to further the solicitor’s position. The Act contains specific provisions defining solicitation of others and when and what you must report. You are a solicitor if you spend more than $3,000.00 in 90 days for soliciting. Solicitors are required to register and file quarterly expenditure reports under oath. For further explanation of regulations and guidelines, see Lobbying Guidelines – General Information (Form LR-GI) • 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 N.C.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®; or (4) • By facsimile (919-807-2205) for filings not requiring a fee, provided the original signed document is received by the Department within seven days following the Department's receipt of the faxed transmission. A filing for which the original is not received or postmarked 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. NO FEE REQUIRED NOTE: REGISTRATION TRIGGERS REPORTING OBLIGATIONS. QUARTERLY REPORTS MUST BE FILED REGARDLESS OF WHETHER THERE ARE ANY REPORTABLE EXPENDITURES. ONCE YOU HAVE REGISTERED AS A SOLICITOR, YOU MUST FILE A QUARTERLY REPORT FOR EVERY SUBSEQUENT QUARTER IN THAT YEAR, EVEN IF YOU DO NOT HAVE ANY EXPENSES. American LegalNet, Inc. www.FormsWorkFlow.com