2017-rGwenButterfield City of Long Beach
LOBBYIST RENEWAL FORM
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INSTRUCTIONS
1, Fill,out fug
2. Sign and date
3. File with the City Clerk by due date with payment enclosed, along with any applicable late
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Long Beach City Clerk's Office
333 W. Ocean Blvd.
Long Beach, CA 90802
Tel. 562 570-6101
This is the Renewal Registration Report due January 15 for:
Lobbyist Name &UI3AeA6(ee
Flier Ip.Number
Calendar Year Covered_
Registration Fees: Persons subject to the registration requirements of this ordinance shall pay an annual
fee of one hundred and five dollars($105.00). The applicable fee is due at the time of registration renewal.
Payment will be deemed delinquent thereafter.A fine of twenty-five dollars($26.85) per day for
delinquent fees,up to a maximum of five hundred dollars ($500.00),will be assessed.
Annual Registration Fee is$105.00
Late Fee Total(if applicable)$—,/—
Total submitted$
Payment Method: Cash Check V
Verification ofiiPerson Responsible for Report Preparation:
Print Name: lea(2i A-�.6 iW-7
Title: hOVyee4)e�
Address: '
I have used all reasonable diligence in preparing this report. I have reviewed all the sections and to the hest of my
knowledge the information contained herein is true and complete.
I certify under penalty of penury under the laws of the State
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