Joint Legislative Ethics Committee 50 West Broad Street, Suite 1308 Columbus, Ohio 43215-5908 (614) 728-5100 www.jlec-olig.state.oh.us FORM #121.63-EMP EMPLOYER OF EXECUTIVE AGENCY LOBBYIST ACTIVITY AND EXPENDITURE REPORT This statement must be filed with the Joint Legislative Ethics Committee by the last day of January, May and September, annually. Please read instructions and review Sections 101.90 to 101.99, Ohio Revised Code, prior to filing. There is no fee for this filing. ANY PERSON WHO KNOWINGLY FILES A FALSE STATEMENT IS GUILTY OF FALSIFICATION UNDER SECTION 2921.13 OF THE OHIO REVISED CODE, WHICH IS A MISDEMEANOR OF THE FIRST DEGREE. Other related prohibitions and penalties are contained in Sections 121.61, 121.65 and 121.99 of the Ohio Revised Code. Any person notified by the joint committee of the failure to file or the filing of an insufficient statement shall, not later than fifteen days after receiving the notice, file a registration statement or an amended registration statement. If any person who receives a notice under this division fails to file a registration statement or such an amended registration statement within this fifteen-day period, the joint committee shall ASSESS A LATE FILING FEE EQUAL TO TWELVE DOLLARS AND FIFTY CENTS PER DAY, UP TO A MAXIMUM OF ONE HUNDRED DOLLARS, UPON THAT PERSON. I. GENERAL INFORMATION Full Name of Employer Business Address of Employer Street State City Suite Number Zip(+4) Telephone Number Contact Person Located at Employer’s Address Provide the name(s) of all Executive Agency Lobbyists engaged by the employer during this reporting period: Name Name (Attached additional sheets, if necessary.) Reporting Period: Year: 200___ ____ Jan-April ____ May-Aug _____ Sept-Dec Due May 31 Due September 30 Due January 31 Page 1 American LegalNet, Inc. www.FormsWorkflow.com II. CHANGES, AMENDMENTS, TERMINATIONS, AND EXECUTIVE AGENCY DECISIONS Employer change of address – Please indicate any changes in Employer registration information from Initial Registration Statement or previous Updated Registration Statement: Name Business Address Street City Suite Number State Zip(+4) Employer Contact___________________________________________________________________ Telephone Number (____) Amended Statement –Indicate if this is an Amended Statement: ______ Yes ______ No If this is an Amended Statement, complete only the section(s) amended. Amended information will replace information previously provided for this reporting period. Terminations – Indicate if the engagement of any Executive Agnecy Lobbyist listed on Page 1 of this form has been terminated during this reporting period: _______ Yes ______ No If yes, please provide the following information: Agent Name: _________________________________ Termination Date: __________________ Agent Name: _________________________________ Termination Date: __________________ Agent Name: _________________________________ Termination Date: __________________ (Attach additional sheets if necessary) EXECUTIVE AGENCY DECISIONS - List any executive agency decisions(s) for which attempts were made to influence during this reporting period: (If none, check here___) (Attach additional sheets if necessary) Page 2 American LegalNet, Inc. www.FormsWorkflow.com III. EXECUTIVE EMPLOYER EXPENDITURE STATEMENT Complete the grid found below to reflect direct Employer expenditures during this reporting period. Expenditures include those made by the Employer as a whole or by any individual on behalf of the Employer, when the individual is not an Executive Agency Lobbyist engaged by the Employer. Please reference the “Expenditure Statement Grid Guidelines” available at www.jlec-olig.state.oh.us for assistance. IF NO EXPENDITURES WERE MADE DURING THIS REPORTING PERIOD, PLACE $0.00 IN THE "TOTAL AGGREGATE" BOX. A. GIFTS Date Recipient Description Executive Decision AMOUNT $ $ $ Description Executive Decision AMOUNT $ $ $ $ B. MEALS AND BEVERAGES Date Recipient C. MEALS PROVIDED AT A MEETING OR CONVENTION OF A NATIONAL ORGANIZATION TO WHICH ANY STATE AGENCY, INCLUDING, BUT NOT LIMITED TO, ANY LEGISLATIVE AGENCY OR STATE INSTITUTION OF HIGHER EDUCATION AS DEFINED IN SECTION 3345.011 OF THE REVISED CODE, PAYS MEMBERSHIP DUES. TOTAL AGGREGATE (Gifts + Meals and Beverage + National Organization) IV. $ DELIVERY OF EXPENDITURE STATEMENT Statements of Non-Disputed Expenditures must be delivered pursuant to Divisions (G)(1) and (2) of Section 121.63, Ohio Revised Code: If detailed expenditure information is being reported in the Gifts or Meal and Beverage section of the Expenditure Statement, then a copy of this Updated Registration Statement containing such information shall be delivered to the public official(s) or employee(s) identified as benefiting from the expenditure(s). Delivery of Expenditure Statement shall occur at least ten (10) days before this form is filed with the Office of the Legislative Inspector General. Date of Delivery: _______________________________ _______________________________ (Attach additional sheets if necessary) If none, check here: _____ Page 3 American LegalNet, Inc. www.FormsWorkflow.com V. FINANCIAL TRANSACTIONS If an Employer of Executive Agency Lobbyist, or an immediate family member of an Employer of Executive Agency Lobbyist, had a Financial Transaction which is not being disputed under Section 121.64, Ohio Revised Code, with or for the benefit of any elected executive official, the director of a department created under Section 121.02, Ohio Revised Code, an executive agency official, or any member of the staff of such public officer or employee, then the following information is required to be completed with respect to each Financial Transaction: Name of the Public Official or Employee: _______________________________________ Brief description of the purpose and nature of the transaction: _______________________ _________________________________________________________________________ Date the transaction was made or entered into: __________________________________ Other pertinent details: ______________________________________________________ _________________________________________________________________________ (Attach an additional sheet for each executive official or employee) Note: If a Financial Transaction is required to be disclosed in Section V of this form, then a copy of this Updated Registration Statement shall be delivered containing such information to the public official(s) or employee(s) identified as party to the Financial Transaction. Delivery of the Updated Registration Statement shall occur at least ten (10) days before this form is filed with the Office of the Legislative Inspector General. Date of Delivery: _____________________________ _____________________________ (Attach additional sheets if necessary) If none, check here: _____ CERTIFICATION: THE UNDERSIGNED HEREBY CERTIFIES THAT ALL REASONABLE EFFORTS AND DUE DILIGENCE HAVE BEEN UNDERTAKEN IN THE PREPARATION AND COMPLETION OF THIS STATEMENT AND THAT THE CONTENTS ARE TRUE AND ACCURATE TO THE BEST OF HIS OR HER KNOWLEDGE. ALL SIGNATURES MUST BE ORIGINAL AND SIGNED PERSONALLY BY THE NAMED INDIVIDUAL. ________________________________ Type or Print Name of Employer Representative _____________________________ Signature of Employer Representative Page 4 ____________ Date American LegalNet, Inc. www.FormsWorkflow.com