MICHIGAN DEPARTMENT OF STATE Clear Form

BUREAU OF ELECTIONS LOBBY REGISTRATION

FINANCIAL REPORT SUMMARY

PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM

1. REGISTRANT’S NAME 2. REGISTRANT’S ID NUMBER

‫ ٱ‬CHECK BOX IF THIS REGISTRANT’S NAME HAS CHANGED 3. TELEPHONE NUMBER ( )

‫ ٱ‬CHECK BOX IF THIS NUMBER HAS CHANGED
4a. MAILING ADDRESS (ALL MAILINGS WILL BE SENT TO THE ADDRESS LISTED HERE)

‫ ٱ‬CHECK BOX IF THIS ADDRESS HAS CHANGED

4b. BUSINESS ADDRESS 4c. IF INDIVIDUAL, RESIDENTIAL ADDRESS

5. TYPE OF 5a. ‫ ٱ‬SUMMER JAN. - JULY ______ (DUE AUG.31) 5d. ‫ ٱ‬TERMINATION OF REGISTRATION
REPORT 5b. ‫ ٱ‬WINTER AUG. - DEC. ______ (DUE JAN. 31)
DATE TERMINATED
5c.‫ ٱ‬AMENDMENT TO ITEM (S) ___________________________ _______________________________________
MONTH DAY YEAR
ENTERING A DATE IN THIS SECTION WILL TERMINATE THE
5e.ITEMIZED EXPENDITURES FORM IS ATTACHED ‫ ٱ‬YES ‫ ٱ‬NO REGISTRATION OF THE PERSON NAMED IN ITEM 1.

6. DESCRIPTION OF ‫ ٱ‬YES - THIS REGISTRANT ENGAGED IN LOBBYING ACTIVITY DURING THIS PERIOD (PROVIDE A BRIEF DESCRIPTION):
LOBBYING
ACTIVITY
DURING THIS
PERIOD
‫ ٱ‬NO - THIS REGISTRANT DID NOT ENGAGE IN LOBBYING ACTIVITY DURING THIS PERIOD

THIS REPORTING PERIOD YEAR TO DATE

7. EXPENDITURES BY CATEGORY JAN. 1 THROUGH THE END OF THE
PERIOD

7a. FOOD AND BEVERAGE FOR PUBLIC OFFICIALS.................................... 7a. $_______________________ 7a. $____________________

7b. MASS MAILINGS AND ADVERTISING............................................................. 7b. $_______________________ 7b. $____________________

7c. ALL OTHER LOBBYING EXPENDITURES ..................................................... 7c. $_______________________

(INCLUDES PAYMENTS TO OTHER PERSONS FOR LOBBYING) 7c. $____________________

7d. TOTAL LOBBYING EXPENDITURES (TOTAL OF 7a, 7b & 7c.)............ 7d. $_______________________ 7d. $____________________

8. ADD OR DELETE EMPLOYEE (S) NAME AND ADDRESS (INDIVIDUALS, FIRMS OR OTHER PERSONS DIRECTLY EMPLOYED,
EMPLOYEES COMPENSATED OR REIMBURSED FOR LOBBYING). THIS ITEM WILL NOT SERVE TO REGISTER, OR TERMINATE THE
REGISTRATION, OF ANY PERSON.

‫ ٱ‬ADD ‫ ٱ‬ADD

‫ ٱ‬DELETE ID#___________________ ‫ ٱ‬DELETE ID#___________________

9. VERIFICATION: I CERTIFY THAT ALL REASONABLE DILIGENCE WAS USED IN THE PREPARATION OF THE ABOVE FORM, AND
THE CONTENTS ARE TRUE AND ACCURATE, TO THE BEST OF MY KNOWLEDGE.

_________________________________________________________ (ALL MAIL WILL BE DIRECTED TO THE SIGNATORY’S ATTENTION.)

TYPE OR PRINT NAME OF AUTHORIZED SIGNATORY

________________________________________________________ ________________________________

SIGNATURE (REGISTRANTS WHO ARE INDIVIDUALS MUST SIGN THEIR OWN FORMS.) MONTH DAY YEAR
LR-3 IT IS UNLAWFUL TO USE THIS INFORMATION FOR ANY COMMERCIAL PURPOSE
AUTHORITY GRANTED UNDER ACT 472 OF THE PUBLIC ACTS OF 1978
 FINANCIAL REPORT SUMMARY – INSTRUCTIONS
A Financial Report Summary must be filed by all registrants – both Lobbyists and Lobbyist Agents. The filing must be made even
if there are no expenditures to report. Financial reports are due on the following dates:

Due Dates Coverage Dates

August 31 January 1 - July 31
January 31 August 1 - December 31

Reports must be received by 4:00 p.m. on the due date to be considered timely. Reports sent by certified
or registered mail and postmarked two or more days before the deadline will be considered timely regardless
of when they are received. Late filing fees will be assessed for each calendar day a report is late.

Every section of the form must be completed. If any section does not apply, enter N/A for not applicable.
Incomplete forms may be rejected and subject to late filing fees.

Item 1. Enter the name of the registrant on whose behalf this report is being submitted. Enter one name only as
each Lobbyist and Lobbyist Agent must submit a separate report. Check the box if the registrant’s name has changed
since the last report was filed. This item cannot be used to register a person under the Lobby Act.

Item 2. Enter the registrant’s identification number. (Note: Each registrant is issued a unique identification
number.)

Item 3. Enter registrant’s telephone number.

Item 4. Enter registrant’s mailing address in 4a. Check the box if the registrant’s mailing address has changed
since the last report was filed. (All mail directed to the registrant through the Department of State, Bureau of Elections
will be sent to the address listed in this item.) Enter the registrant's business address in 4b. If the registrant is an
individual, address in 4c.

Item 5. Indicate the type of report being filed (5a for Summer or 5b for Winter) and the year of the report. If the
report is being filed to amend a previous report, complete 5c and list the affected items. If the registrant named in
Item 1 no longer meets the definition of a Lobbyist or Lobbyist Agent and wishes to terminate the registration,
complete 5d and enter the effective date of the termination. Complete 5e to indicate if the registrant made any
expenditures, which are itemized on an attached Itemized Expenditures form.

Item 6. Briefly describe the registrant’s lobbying activities during the period covered by this report and place a
check mark in the appropriate box. Example: Lobbied (for or against) passage of legislation concerning (briefly
summarize legislation). If the registrant did not engage in any lobbying activities during the period covered by
this report, place a check mark in the box indicting there was no lobbying activity.

Item 7. Enter totals for all direct expenditures made by the registrant during the period covered by this report
(This Reporting Period) and since January of the year covered by the report (Year to Date).
Item 7a - Food and Beverage Provided to Public Officials (Reported regardless of purpose.)
Item 7b - Mass Mailing and Advertising (1000 pieces or more of similar mail sent within a 7-day period.)
Item 7c - All Other Lobbying Expenditures (Salary for Lobbyist Agents and other lobbying expenditures.)
Expenditures or compensation contingent upon the outcome of a legislative or administrative action is
prohibited.

Item 8. Enter the name and business address of each person (to be added or deleted) employed, compensated
or reimbursed by the registrant, named in Item 1, more than the current thresholds during any 12 month period
for lobbying. The entry of a person’s name, under Item 8, does not register or terminate the person under the Lobby Act.

Item 9. Sign the report. The report must be signed by the Lobbyist or Lobbyist Agent; if the registrant is not an
individual, the report must be signed by a person authorized by the registrant. An original signature must be provided.
Mail will be directed to the attention of the person who signs under Item 9.

Mail to: Michigan Dept. of State, Bureau of Elections Phone: (517) 373-2540 Web: www.michigan.gov/elections

For U.S. Mail: For overnight delivery services, or to visit our office:
Post Office Box 20126 Richard H. Austin Building – 1st Floor, 430 West Allegan Street
Lansing, Michigan 48901-0726 Lansing, Michigan 48918