EXECUTIVE LOBBYING EXPENDITURE REPORT FORM 507 FOR OFFICE USE ONLY Postmark Date__________ |
|
[] COVERING JANUARY 1- JUNE 30, _____ - DUE AUGUST 15 [] COVERING JANUARY 1 - DECEMBER 31, _____ - DUE FEBRUARY 15 Mail to: The Board of Ethics, 3415 Quail Drive, Third Floor, Baton Rouge, LA 70808 OR Fax to: (225) 763-8787 or (225) 763-8780 |
________________________________ Executive Lobbyist Registration No. |
FOR OFFICE USE ONLY Postmark Date__________ |
1. NAME _________________________________________________________________________ Last First MI
NAME CHANGE_________________________________________________________________
Last First MI
2. BUSINESS ADDRESS _____________________________________________________________ Street and No. City State Zip
MAILING ADDRESS ______________________________________________________________
Street and No. City State Zip
3. BUSINESS PHONE _______________________________________________________________ Area Code and Phone Number
4. Total of all executive lobbying expenditures made January 1 through June 30: $ ________________________________________ (Include expenditures from Schedules A and B)
5. Total of all executive lobbying expenditures made July1 through December 30: $ ________________________________________ (When Applicable) (Include expenditures from Schedules A and B)
6. Total of all executive lobbying expenditures made during calendar year: $ ________________________________________ (Line 4 added to Line 5 should equal Line 6)
7. Did you make an expenditure exceeding $50 on one occasion for an executive branch official: From January 1 through June 30? [] Yes [] No
From July 1 through December 31? [] Yes [] No [] NA
If the answer to either question in Number 7 above is YES, complete Schedule A and attach.
8. Did you make expenditures exceeding the sum of $250 for an executive branch official: From January 1 through June 30? [] Yes [] No
From July 1 through December 31? [] Yes [] No [] NA
If the answer to either question in Number 8 above is YES, complete Schedule A and attach.
9. Did you expend funds for any reception, social gathering, or other function to which more than twenty-five executive branch officials were invited during this reporting period? Yes [] No []
If the answer to Number 9 above is YES, complete Schedule B and attach.
EXECUTIVE LOBBYING EXPENDITURE REPORT
________________________________ Executive Lobbyist Registration No. |
10. PROVIDE BELOW (a) the name of the executive branch department as listed in the executive branch schedule;(b) the aggregate total of all expenditures attributable to the department made during the January 1 - June 30 reporting period;(c) the aggregate total of all expenditures attributable to the department made during the July 1 - December 31 reporting period when applicable;(d) the aggregate total of all expenditures made in a calendar year attributable to the department.1)b. Total of all expenditures made January 1 through June 30: $c. Total of all expenditures made July 1 through December 31: $ (When applicable)
d. Total of all expenditures made during the calendar year: $2)b. Total of all expenditures made January 1 through June 30: $c. Total of all expenditures made July 1 through December 31: $ (When applicable)
d. Total of all expenditures made during the calendar year: $3)b. Total of all expenditures made January 1 through June 30: $c. Total of all expenditures made July 1 through December 31: $ (When applicable)
d. Total of all expenditures made during the calendar year: $11. PROVIDE BELOW (a) the name of the executive branch department and the individual agency as listed in the executive branch schedule;(b) the aggregate total of all expenditures attributable to the agency made during the January 1 - June 30 reporting period;(c) the aggregate total of all expenditures attributable to the agency made during the July 1 - December 31 reporting period when applicable;(d) the aggregate total of all expenditures made in a calendar year attributable to the agency.1)a. Name of Department and Individual Agency: ____________________________ b. Total of all expenditures made January 1 through June 30: $c. Total of all expenditures made July 1 through December 31: $ (When applicable)
d. Total of all expenditures made during the calendar year: $2)a. Name of Department and Individual Agency: ____________________________ b. Total of all expenditures made January 1 through June 30: $c. Total of all expenditures made July 1 through December 31: $ (When applicable)
d. Total of all expenditures made during the calendar year: $3)a. Name of Department and Individual Agency: ____________________________ b. Total of all expenditures made January 1 through June 30: $c. Total of all expenditures made July 1 through December 31: $ (When applicable)
d. Total of all expenditures made during the calendar year: $CERTIFICATION OF ACCURACY
I hereby certify that the information contained herein is true and correct to the best of my knowledge, information, and belief; that all reportable expenditures have been included herein; and that no information required by LSA-R.S. 49:71 et seq. has been deliberately omitted.
_________________________________
Signature of Lobbyist
SCHEDULE A: EXPENDITURES FOR EXECUTIVE BRANCH OFFICIALS |
This schedule must be completed if you answered YES to either question 7 or 8 on the Executive Lobbying Expenditure Report. If, during the period January 1 through June 30 or the period July 1 through December 31, you made either a) an expenditure for any executive branch official exceeding $50 on any one occasion or b) aggregate expenditures exceeding $250 for any one executive branch official during a reporting period, then you must provide the aggregate total of expenditures made on that individual in that reporting period. NOTE: Report covering July - December is cumulative. You must include reportable expenditures from the first half of the year in Column #3. |
1. EXECUTIVE OFFICIAL'S NAME | 2. OFFICIAL'S AGENCY AS LISTED IN THE EXECUTIVE BRANCH SCHEDULE | 3. AMOUNT OF EXPENDITURES MADE ON AN OFFICIAL FOR WHOM YOU EITHER SPENT OVER $50 ON ONE OCCASION OR MADE EXPENDITURES EXCEEDING $250 BETWEEN JANUARY 1 AND JUNE 30 | 4. AMOUNT OF EXPENDITURES MADE ON AN OFFICIAL FOR WHOM YOU EITHER SPENT OVER $50 ON ONE OCCASION OR MADE EXPENDITURES EXCEEDING $250 BETWEEN JULY 1 AND DECEMBER 31 | 5. TOTAL OF COLUMNS 3 AND 4 |
SCHEDULE B: EXPENDITURES FOR RECEPTIONS, ETC. |
This Schedule must be completed if you answered YES to question 9 on the Executive Lobbying Expenditure Report. The following information must be provided for all receptions, social gatherings, or other functions to which more than twenty-five executive branch officials were invited. List the name of the group or groups invited, the date of the event, physical location of the event including the city, and the total amount expended. |
1. NAME(S) OF GROUP(S) INVITED | 2. DATE OF RECEPTION | 3. LOCATION OF RECEPTION | 4. TOTAL AMOUNT OF EXPENDITURES |
EXECUTIVE LOBBYING EXPENDITURE REPORT
ATTACHMENT
________________________________ Executive Lobbyist Registration No. |
Instructions: · Please make as many copies as necessary to complete Item #11 of your executive lobbying expenditure report. · Fill in your executive lobbyist registration number in the space provided in the upper right hand corner of the page. · Identify each page with a page number and indicate the total number of pages being submitted. |
1)a. Name of Department and Individual Agency: ____________________________ b. Total of all expenditures made January 1 through June 30: $___________c. Total of all expenditures made July 1 through December 31: $ ____________ (When applicable)
d. Total of all expenditures made during the calendar year: $_______________2)a. Name of Department and Individual Agency: ____________________________ b. Total of all expenditures made January 1 through June 30: $_________c. Total of all expenditures made July 1 through December 31: $________________ (When applicable)
d. Total of all expenditures made during the calendar year: $________________ 3)a. Name of Department and Individual Agency: ____________________________ b. Total of all expenditures made January 1 through June 30: $_________c. Total of all expenditures made July 1 through December 31: $______________ (When applicable)
d. Total of all expenditures made during the calendar year: $___________4)a. Name of Department and Individual Agency: ____________________________ b. Total of all expenditures made January 1 through June 30: $_____________ c. Total of all expenditures made July 1 through December 31: $ ___________ (When applicable)
d. Totalof all expenditures made during the calendar year: $ __________La. Admin. Code tit. 52, § I-2137
Promulgated by the Department of Civil Service, Board of Ethics, LR 31:1243 (June 2005).AUTHORITY NOTE: Promulgated in accordance with R.S. 42:1134(A).