Lobbyist Activity Report

Office of the City Clerk
P.O. Box 1088
Austin, Texas 78767

This report is for persons who are registered as lobbyists and, during the preceding calendar quarter, have reportable lobbying activity under City Code 4-8-7. No quarterly activity report is required if there has been no activity during the preceding quarter and there are no changes to the original application.

This report must be filed with the City Clerk between the first and tenth day of April, July, October and January. The report must be signed under oath.

File a separate activity report for each person from whom the registered lobbyist received compensation or reimbursement.

If information which is required by City Code 4-8-6 on either the registrant or the entity on whose behalf the registrant has lobbied is no longer accurate or if the information needs to be updated, complete and file the Lobbyist Amendment Form and file it with the Lobbyist Activity Report.

	

Registrant Information :	Last Name:
     	First Name:
     	Middle Initial:
 	

Entity of whose behalf the registrant has lobbied:      
This report is filed on the following date:      
The report covers activity during the previous calendar quarter.              

List your total expenditures on lobbying broken down into the following categories.

	
Type of expenditure	Amount	
Office Expenses	$     	
Advertising and Publications	$     	
Compensation to Other Than Full-Time Employees	$     	
Reimbursement to Others	$     	
Total Personal Sustenance, Lodging and Travel	$     	
Other Expenses	$     	
Total Expenses	$     	

From your total expenditures on lobbying as reported above, list any single expenditure which exceeds $500 and provide the following information:

	
Date of Expenditure:	Vendor (recipient) name:	Vendor (recipient) address:	Amount:	Purpose:	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	

List all expenditures, gifts, or honorariums of $100 or MORE made by the registrant or anyone acting on behalf of the registrant to benefit a city official:

Date:	Beneficiary:	Amount:	Circumstances of the transaction: 	
     	     	$     	     	
     	     	$     	     	
     	     	$     	     	
     	     	$     	     	
     	     	$     	     	
     	     	$     	     	

Aggregate of all such expenditures less than $100 each: $     

Provide the required information for each business entity in which the registrant knows or should know that a city official is a proprietor, partner, director, officer, manager, employer,
employee, or has a substantial economic interest and with whom the registrant has engaged in an exchange of money, goods, services, or anything of value, if the total of such exchanges is $500 or more in a calendar quarter.

Date:	Name of official:	Name of Business entity:	Address of business entity:	Amount:	Nature of such exchange: 	
     	     	     	     	$     	     	
     	     	     	     	$     	     	
     	     	     	     	$     	     	
     	     	     	     	$     	     	

If the registrant employs the Mayor, members of Council or their immediate family, please
state below:

	
Employee’s Name:	Nature of Employment:	
     	     	
     	     	
     	     	

STATE OF TEXAS
COUNTY OF TRAVIS

AFFIDAVIT

I swear or affirm under penalty of perjury that this Lobbyist Activity Report is true and correct and includes all information required to be reported by me pursuant to Section 4-8-6 of the Austin City Code of 2003 for the reporting period indicated.

__________________________
Signature of Affiant

SWORN TO AND SUBSCRIBED BEFORE ME by the said ____________________________,
on this the _______ day of _________________________, 201____, witness my hand and seal of office.

__________________________
Signature of Notary

(SEAL)