LOBBYING REGISTRATION STATEMENT

LOBBYING REGISTRATION STATEMENT
CARROLL COUNTY ETHICS COMMISSION

225 N. Center Street, Room 113 Westminster, Maryland 21157
1. Fill in the identification information requested in boxes below. Be sure to correctly identify the reporting period. The deadline for the previous years report is on or before January 15 of the calendar year.

2. Complete Schedule A regarding any food, entertainment, or other gifts provided to any County official or employee.

3. Upon completion of your Lobbying Registration Statement, sign and date the lower portion of the page and make the required oath or affirmation before a notary public or other officer authorized to take oaths.

4. This statement will be maintained by the Ethics Commission as a public record available for public inspection and copying.
Reporting Period Year January 1, through December 31,
Reporting Period Year January 1, through December 31,
enter the year
(Registrant’s Full Name)
(Registrant’s Address)
(City and State)
(Registrant’s Phone Number)
(Person or Entity on Whose Behalf the Registrant Acts)
(Address)
(City and State)
(Phone Number)
Subject matter on which the Registrant has made appearances
This Lobbying Registration Statement describes all matters required to be disclosed by the Carroll County Ethics Law with respect to the period indicated and pertaining to the person filing the statement. The statement consists of this cover sheet and Schedule A.

I hereby make oath or affirm that the contents of this Lobbying Registration Statement, including Schedule A, are true and correct to the best of my knowledge, information and belief.
Signature of Person Filing:

Clear
Date

MonthDayYear
Date
Sworn to before me this _

MonthDayYear
Date
Signature of Notary Public:

Clear
Printed/typed name of Notary Public:
My Commission Expires:

MonthDayYear
Date
SCHEDULE A: Food, entertainment, or other gifts provided to County officials or employees during reporting period. (This schedule must be filed on a annual basis only if gifts are given.)
1. Nature and Value of food, entertainment or gift (if cash, give amount; other, describe and state its value)
2. Date
3. *Person whom gift was given to
Should be Empty:

LOBBYING REGISTRATION STATEMENT

Reporting Period Year January 1, through December 31,