|Clerk of the House of Representatives|
Legislative Resource Center
B-106 Cannon Building
Washington, DC 20515
|Secretary of the Senate
Office of Public Records
232 Hart Building
Washington, DC 20510
Lobbying Disclosure Act of 1995 (Section 4)
|1. Effective Date of Registration|
|2. House Identification||Senate Identification|
REGISTRANT Organization/Lobbying Firm Self Employed Individual
|5. Contact name and telephone number||International Number|
CLIENT A Lobbying Firm is required to file a separate registration for each client. Organizations employing in-house lobbyists should check the box labeled “Self” and proceed to line 10. Self
|7. Client name|
10. Name of each individual who has acted or is expected to act as a lobbyist for the client identified on line 7. If any person listed in this section has served as a “covered executive branch official” or “covered legislative branch official” within twenty years of first acting as a lobbyist for the client, state the executive and/or legislative position(s) in which the person served.
|Name||Covered Official Position (if applicable)|
11. General lobbying issue areas (Select all applicable codes).
12. Specific lobbying issues (current and anticipated)
Medicare and Medicaid
13. Is there an entity other than the client that contributes more than $5,000 to the lobbying activities of the registrant in a quarterly period and either actively participates in and/or in whole or in major part supervises, plans, or controls the registrant’s lobbying activities?
|No --> Go to line 14.||Yes --> Complete the rest of this section for each entity matching the criteria above, then proceed to line 14.|
|Name||Address||Principal Place of Business|
14. Is there any foreign entity
a) holds at least 20% equitable ownership in the client or any organization identified on line 13; or
b) directly or indirectly, in whole or in major part, plans, supervises, controls, directs, finances or subsidizes activities of the client or any organization identified on line 13; or
c) is an affiliate of the client or any organization identified on line 13 and has a direct interest in the outcome of the lobbying activity?
|No --> Sign and date the registration.||Yes --> Complete the rest of this section for each entity matching the criteria above, then sign the registration.|
|Name||Street||Principal place of business||Amount of contribution|
|(city and state or country)||for lobbying activities|