2013-rGwenButterfield City of Long Beach
LOBBYIST RENEWAL FORM
f_ n I i P 'DgWnload Form
1. Fill out form INSTRUCTIONS 13 Jflfq 5 PM 4: 20
2. Sign and date
3. File with: Long Beach City Clerk's Office
333 W. Ocean Blvd.
Long Beach, CA 90802
Tel. 562 570-6101
O This is the Renewal Registration Report due January 15 for:
Lobbyist Name:
Filer ID Number: l l ^ b<
Renewal for Calendar Year: 01013
Registration Fees: Persons subject to the registration requirements of this ordinance shall pay an annual
fee of one hundred dollars ($100.00).The applicable fee is due at the time of registration renewal. Payment
will be deemed delinquent thereafter. Late Fees will be assessed on a per day basis in accordance with Long
Beach Municipal Code 2.80,and the most recent Fee Schedule approved by Long Beach City Council.
http://www.longheach.gov/finance/fees and charges/
➢ Annual Registration Fee: $ 100.00
J
i
➢ Late Fee Total(if applicable) $
I
➢ Total submitted $
Payment Method: ® Cash ® Check No:
Verification of Person Responsible for Report Preparation:
Print Name: �--d V l S G, , jA(L( ET TO J-R
Title: S B V ZEZ> S&TN LL's
Address: ��
I have used all reasonable diligence in preparing this report, I have reviewed all the sections and to the best of my
knowledge the information contained herein is true and complete.
I certify under penalty of perjury under the laws of the State
Date: �� Signature:
City of Long Beach Lobbyist Renewal Report Form—10/2012 Page 1 of I