LOBBYIST EXPENDITURE REPORT SECRETARY OF STATE SFN 07654 (03-2018) WO Number:For Office Use Only ID Number: Filed: By:REPORT DUE: AUGUST 1, 2018 FILING FEES: No fee if filed after June 30, 2018, but on or before August 1, 2018 $25.00 if filed after August 1, 2018, but on or before October 1, 2018 $50.00 if filed after October 1, 2018 SEE INSTRUCTIONS FOR FILING, AND MAILING INFORMATION.For reference, see North Dakota Century Code, Chapter 54-05.1. 1.Lobbyist name 2.Business telephone number 3.Lobbyist business address City State ZIP code 4.For the period between July 1, 2017 and June 30, 2018, do you have any expenditures of $60 or more to report? No - Sign the report in number 6 Yes - Provide the information in number 5 and sign the report in number 6 5.If you answered "yes" to number 4 above, provide the following details regarding expenditures of $60 or more.DATE OF EXPENDITURENATURE OF EXPENDITURE AND ON WHOSE BEHALF EXPENDEDNAME OF EXPENDITURE RECIPIENTAMOUNT OF EXPENDITURE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Date Signature 6.The undersigned has read the foregoing and knows the contents thereof to be true. American LegalNet, Inc. www.FormsWorkFlow.com SFN 07654 (03-2018)Page 2 of 2LOBBYIST EXPENDITURE REPORT Each registered lobbyist must file an expenditure report with the Secretary of State on or before August 1 following the expiration of the lobbyist registration period. For 2018, the report is due on or before August 1, 2018, and covers the lobbyist registration period from July 1, 2017 through June 30, 2018. Every registered lobbyist must file this report even if he or she does not have any expenditures to report. Lobbyists must report expenditures of $60 or more expended on any single occasion on any individual, including the spouse or other family member of the legislative assembly or the governor, in carrying out the lobbyist's work. Submit the filing fee if the report is not filed on or before August 1, 2018. FILING FEE: No fee if filed after June 30, 2018, but on or before August 1, 2018 $25.00 if filed after August 1, 2018, but on or before October 1, 2018 $50.00 if filed after October 1, 2018 Checks must be payable to "Secretary of State" and must be for U.S. negotiable funds. Payment may also be made by credit card using Visa, MasterCard, Discover, or American Express. The following numbered instructions correspond to the numbered sections on the form: 1.Provide the name of the lobbyist.2.Provide the business telephone number of the lobbyist.3.Provide the business address.4.Answer "Yes" or "No" to indicate whether the lobbyist has expenditures to report of $60 or more expended on any single occasion. If"No," proceed to number 6; if "Yes," proceed to number 5.5.For each reportable expenditure, provide the date of the expenditure, describe the nature of the expenditure and on whose behalfexpended, the name of the expenditure recipient, and the amount of the expenditure.6.The report must be signed and dated by the lobbyist.ASSISTANCE: If assistance is required to complete the report, contact the Secretary of State at (701) 328-3665. FAX FILING: The report and Credit Card Payment Authorization may be faxed to (701) 328-1690. A faxed filing does not expedite the process of the document in the Secretary of State's office. EMAIL: Email is not a secure utility for transmission of private information or credit card authorizations. DO NOT EMAIL YOUR DOCUMENT TO THE SECRETARY OF STATE. MAILING INSTRUCTIONS: Send the completed report (and payment if mailing after the due date) to: Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500 Telephone: (701) 328-3665 Toll-free: (800) 352-0867 (ext. 328-3665) Fax: (701) 328-1690 Website: sos.nd.gov WO Number (For Office Use Only): CREDIT CARD PAYMENT AUTHORIZATION SECRETARY OF STATE SFN 51478 (02-2016) Amount . Name Telephone Number Address City State ZIP Code Card Type Visa MasterCard Discover American Express Signature (required by credit card companies) Account Number CSC Number* Card Expires (MMYY) Date*Three-digit (Visa, MasterCard, or Discover) or four-digit (American Express) security code American LegalNet, Inc. www.FormsWorkFlow.com