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-AGT EXECUTIVE AGENCY LOBBYIST ACTIVITY AND EXPENDITURE REPORT This statement must be filed with the Office of the Legislative Inspector General by the last day of January, May and September, annually. Please read instructions and review Sections 121.60 to 121.99, Ohio Revised Code, prior to filing. There is no fee for this filing. Upon termination of an engagement, there is an affirmative duty to notify the Office of the Legislative Inspector General of any termination of engagement within thirty (30) days (the form may be obtained from the OLIG). 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 Office of the Legislative Inspector General 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 Office of the Legislative Inspector General 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 Executive Agency Lobbyist Business Address Street City Suite number State Zip(+4) Telephone Number Agent Change of Name or Address Please indicate any changes in Agent registration information from the Initial Registration Statement or previous Updated Registration Statement (If none, check here ____): Name of Executive Agency Lobbyist Address Street Suite Number State Zip(+4) City Telephone Number (_______) 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. AMENDMENTS, TERMINATIONS AND ADDITIONAL EXECUTIVE OFFICIALS, DEPARTMENTS, OR AGENCIES AMENDED STATEMENT – Indicate if this is an Amended Statement ____YES _____NO If this is and Amended Statement, complete only the section(s) amended. Amended information will replace information previously reported for this reporting period. TERMINATIONS – Indicate if the engagement with any Employer of Executive Agency Lobbyist has been terminated during this reporting period: _____YES _____NO If yes, please provide the following information: Employer Name Date of Termination (Attach additional sheets if necessary.) ADDITIONAL EXECUTIVE OFFICIALS, DEPARTMENTS OR AGENCIES – List any additional Executive Officials, Departments or Agencies to which any engagements related during this reporting period: Employer Name Executive Agency Official or Agency (If none, check here_______) III. EXECUTIVE AGENCY LOBBYIST EXPENDITURE STATEMENTS Complete a separate Expenditure Statement grid for each Employer for which an engagement was effective at any time during this reporting period. Each Expenditure Statement grid should reflect expenditures attributable to the Employer listed in the heading of the grid. 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. Page 2 American LegalNet, Inc. www.FormsWorkflow.com NAME OF EMPLOYER: A. GIFTS Date B. Recipient Description Decision AMOUNT $ $ $ Description Decision AMOUNT $ $ $ $ MEALS AND BEVERAGES Date Recipient C. MEALS - UNDER $50; SPEAKING ENGAGEMENT; 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 Beverages + Meals Under $50) $ Please disclose specific executive agency decisions on which active advocacy occurred during this reporting period: NAME OF EMPLOYER: A. GIFTS Date B. Recipient Description Decision AMOUNT $ $ $ Description Decision AMOUNT $ $ $ $ MEALS AND BEVERAGES Date Recipient C. MEALS - UNDER $50; SPEAKING ENGAGEMENT; 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 Beverages + Meals Under $50) $ Please disclose specific executive agency decisions on which active advocacy occurred during this reporting period: Page 3 American LegalNet, Inc. www.FormsWorkflow.com 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 executive agency 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: _____ V. FINANCIAL TRANSACTIONS If an Executive Agency Lobbyist, or an immediate family member of an Executive Agency Lobbyist, had a Financial Transaction which is not being disputed under Section 121.65, Ohio Revised Code, with or for the benefit of an 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: a. Name of the Executive Official or Employee: ________________________________________________ b. Brief description of the purpose and nature of the transaction: ___________________________________ _______________________________________________________________________________________ c. Date the transaction was made or entered into: ________________________________________________ d. 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 Executive 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 Executive Agency Lobbyist Signature of Executive Agency Lobbyist Date Page 4 American LegalNet, Inc. www.FormsWorkflow.com