LAC 52:I.2135. Executive Lobbying Expenditure Reporting Designation

EXECUTIVE LOBBYING EXPENDITURE REPORTING DESIGNATION Pursuant to LSA-R.S. 49:76G(2)(a), an employer or principal of a lobbyist may elect to file the Lobbying Expenditure Reports as required by Title 49 on behalf of all of its lobbyists. The designation form is to be completed and submitted by January 31st of each year. This designation will be effective for the reporting of all expenditures made during that calendar year. This form must include a listing of all persons for whom you will be reporting. Also, please list a contact person who will be responsible for completing such reports and for receiving any correspondence regarding reporting deadlines and late fees. Failure to fully complete this form may render your designation ineffective. Hand deliver or mail to: 2415 Quail Drive, 3rd Floor, Baton Rouge, LA 70808 OR Fax to: (225) 763-8787 or (225) 763-8780 1. EMPLOYER/PRINCIPAL 2. BUSINESS ADDRESS Street and No. City State Zip MAILING ADDRESS Street and No. City State Zip 3. CONTACT PERSON: Last First MI 4. MAILING ADDRESS (If different from above) Street and No. City State Zip 5. PHONE NUMBER Area Code and Phone Number 6. FAX NUMBER Area Code and Fax Number 7. Names of Lobbyists who are employed by or who represent the interests of the Principal listed above: 1) Name: EXEC.ID.#_______________ Last First MI 2) Name: EXEC.ID.#_______________ Last First MI 3) Name: EXEC.ID.#_______________ Last First MI Page 1 of 2 4) Name: EXEC.ID.#_______________ Last First MI 5) Name: EXEC.ID.#_______________ Last First MI 6) Name: EXEC.ID.#_______________ Last First MI 7) Name: EXEC.ID.#_______________ Last First MI 8) Name: EXEC.ID.#_______________ Last First MI 9) Name: EXEC.ID.#_______________ Last First MI 10) Name: EXEC.ID.#_______________ Last First MI Pursuant to LSA-R.S. 49:76G(2)(a), ______________________________________ (name of employer or principal) is exercising the option of filing expenditure reports for all executive lobbying expenditures made of my/its behalf by persons representing my/its interests during the year of _________. I hereby certify that the information contained herein is true and correct to the best of my knowledge, information and belief; and that no information required by LSA-R.S. 49:71 et seq. has been deliberately omitted. ___________________________________________ Signature of Employer/Principal or Representative ___________________________________________ Print of Type Full Name Page 2 of 2