2016-rJimmyBlackman Date Stamp
City of Long Beach
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LOBBYIST RENEWAL FORM 'a' CLERK
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16 JAN -6 • !"m
INSTRUCTIONS
1. Fill out form
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:
Jimmy Blackman
Filer ID Number: CLB-15-031
Renewal for Calendar Year: 2016
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.longbeach.gov/finance/fees and charges/
➢ Annual Registration Fee: $ 100.00
➢ Late Fee Total(if applicable) $
➢ Total submitted $
100.00
Payment Method: ❑ Cash 0 Check No: 3S�
Verification of Person Responsible for Report Preparation:
Print Name: Jimmy Blackman
Title:
President
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
January 4, 2016
Date: Signature:
City of Long Beach Lobbyist Renewal Report Form— 10/2012 Page 1 of 1