Form SA-RS Page 1 of 2 (Rev. 12/08) Please type, print in ink or file on-line Office use only File # Elaine F. Marshall, Secretary of State State Agency Authorization Statement For Liaison Personnel 2009 NO FEE REQUIRED State Agency Information Complete Name of State Agency*:______________________________________________________________ Address of State Agency (Physical):_____________________________________________________________ _________________________________________________________________________________________ Complete Name and Title of Agency Contact Person:_______________________________________________ Mailing Address of Contact Person:_____________________________________________________________ __________________________________________________________________________________________ Telephone No. of Contact Person:_______________________________ Fax No.:________________________ E-Mail Address of Contact Person:_____________________________________________________________ Liaison Personnel Information (State Employee as Liaison) Complete Name of Liaison:___________________________________________________________________ Business Address of Liaison (Physical):__________________________________________________________ __________________________________________________________________________________________ Mailing Address of Liaison:___________________________________________________________________ __________________________________________________________________________________________ Telephone No. of Liaison:___________________________________ Fax No.:__________________________ E-mail Address of Liaison: ___________________________________________________________________ • The State Agency means 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. Information included on this form should correspond to information provided on the Liaison Registration Statement (Form LR-RS). American LegalNet, Inc. www.FormsWorkflow.com Form SA-RS Page 2 of 2 (Rev. 12/08) Report Preparer’s Identity/Signature (Rule 18 NCAC 12.0209) Printed Complete Name of Report Preparer: ___________________________________________________ Signature of Report Preparer: _______________________________________________________________ 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 below and you will be invoiced according to N.C.G.S. § 132-1(b). CERTIFICATION I hereby certify that all information disclosed in this “State Agency Authorization Statement 2009” is true, complete and correct in accordance with Article 2 of N.C.G.S. §120C. By signing this certification, I understand the State Agency through its authorized official or representative has an affirmative duty to understand the rules and to comply with the Lobbying Law,including filing the required reports. ________________________________________________________ _______________________________ DATE SIGNATURE OF STATE AGENCY CONTACT PERSON • The authorization will expire on January 1 of the following year unless written notification is received prior to that date. The state agency shall file a new authorization statement after that date. No fee is required. • 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, NC 27626-0622; (2) In person or by a designated delivery service authorized pursuant to G.S. 1A-1, Rule 4 at the following street address: Lobbying Compliance Division, Department of the Secretary of State, 2 South Salisbury Street, Raleigh, NC 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 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. For further explanation of regulations and guidelines, see Lobbying Guidelines -- General Information (Form LR-GI) NOTE: REGISTRATION TRIGGERS QUARTERLY LIASION REPORTS MUST REPORTABLE EXPENDITURES. REPORTING OBLIGATIONS FOR THE LIASION ONLY. BE FILED REGARDLESS OF WHETHER THERE ARE ANY American LegalNet, Inc. www.FormsWorkflow.com