Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) LOBBY ELECTRONIC FILING PASSWORD Please print or type everything other than your signature. See back for additional explanation about completing this document. 2 REGISTRANT NAME Mr Mrs Ms FORM LOBBY PASS 1 Registrant Account # (if known) OFFICE USE ONLY Date Received 3 CONTACT NAME IF REGISTRANT IS AN ENTITY REGISTRANT'S MAILING ADDRESS ADDRESS APT / SUITE #; CITY; STATE; ZIP CODE 4 5 REGISTRANT'S E-MAIL ADDRESS (For Commission to send filing requirement notices) REGISTRANT'S TELEPHONE NUMBER REGISTRANT'S SECURITY QUESTION ANSWER TO REGISTRANT'S SECURITY QUESTION REGISTRANT'S SIGNATURE AREA CODE PHONE NUMBER EXTENSION Date Hand-delivered or Postmarked Password 6 ( ) 7 8 9 I swear that I am the person required by Chapter 305, Government Code, to file lobby reports with the Texas Ethics Commission. Signature of Registrant 10 IF APPLICABLE, CHECK HERE I authorize the Texas Ethics Commission to release my password to ________________________________________ Name _____________________ Phone # www.ethics.state.tx.us Revised 06/12/2013 American LegalNet, Inc. www.FormsWorkFlow.com Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) LOBBY ELECTRONIC FILING PASSWORD Passwords are used to enable you to file Texas Ethics Commission lobby reports electronically. The Ethics Commission electronic filing software uses your unique password and the Ethics Commission registrant account number* to digitally encrypt and sign your electronic lobby reports. To receive a password, the person responsible for filing reports must complete this form and return it by mail to the Texas Ethics Commission, P.O. Box 12070, Austin, TX 78711-2070, by fax to 512-463-8808, or by hand-delivery to 201 E. 14th St., Sam Houston Bldg., 10th Floor, Austin, TX 78701. It is your responsibility to protect your password. If you forget your password, contact the Ethics Commission at one of the numbers listed above. You will be given your password ONLY after you correctly answer the question you provided in Box #7. INSTRUCTIONS FOR COMPLETING Form LOBBY PASS The following numbers correspond to the numbered boxes on Form LOBBY PASS. 1. Registrant Account #. Enter the registrant account number assigned by the Ethics Commission. Please note that the registrant account number is NOT the same as the official password to file electronically. *If you are a first time registrant and do not have an account number, the Ethics Commission will issue an account number along with a password. 2. Name of Registrant. Enter your name. 3. Contact Name if Registrant is an Entity. Enter the name of an individual that will serve as a contact person for the Texas Ethics Commission if the registrant is an entity. 4. Registrant's Mailing Address. Enter the address of the registrant requesting the password. The Ethics Commission will mail the official password by certified mail to the address provided. 5. Registrant's E-Mail Address. Enter the e-mail address of the registrant requesting the password. 6. Registrant's Telephone Number. Enter the telephone number of the registrant requesting the password, including the area code and, if applicable, the extension number. 7. Registrant's Security Question. Enter a question. Choose a question to which only you know the answer. If you forget your password, this is the question you will be required to correctly answer before the Ethics Commission gives you your password. 8. Answer to Registrant's Security Question. Enter the answer to the question you entered in Box #7. For your security and convenience, make sure the answer is something that only you know and that is extremely difficult for others to guess, even if they are asked your question. If you forget your password, this is the answer you will be required to give to the question in Box #7 before the Ethics Commission gives you your password. 9. Registrant's Signature. Sign after reading the statement. 10. If Applicable, Check Here. If you will not be available to obtain your password from the Ethics Commission, you may authorize the release of your password to the person you name. (The password will be released to the person you name when the security question you provided in Box #7 is answered.) www.ethics.state.tx.us Revised 06/12/2013 American LegalNet, Inc. www.FormsWorkFlow.com