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City of Long Beach CITYU It i,
LOBBYIST RENEWAL FORM
18 JAN 17 FN 2: 15
INSTRUCTIONS
1. Fill out form
2. Sign and date
3. File with the City Clerk by due date with payment enclosed, along with any applicable late
fees.
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 AAey►can 1444 i (±Aw4 olssacia�o-k
T
Filer ID Number /y04- y4F Alceiv-j
Calendar Year Covered ZO l g
Registration Fees: Persons subject to the registration requirements of this ordinance shall pay an annual
fee of one hundred and seven dollars ($107.00).The applicable fee is due at the time of registration renewal.
Payment will be deemed delinquent thereafter.A fine of twenty-seven dollars and forty-five cents($27.45)
per day for delinquent fees,up to a maximum of five hundred dollars($500.00),will be assessed.
Annual Registration Fee is $107.00
Late Fee Total(if applicable)$ 0
Total submitted$ /07,00
Payment Method: Cash Check
;i
Verification of Person Responsible for Report Preparation:
Print Name:
Title: 0&) p�iOLhC 1V1 6l.K.41e_r /
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 of California that the foregoing is true and correct.
Date: Signature:
City of Long Beach Lobbyist Renewal Report Form—11/7/2017 Page 1 of 1