Office of the Secretary of the Commonwealth
Commonwealth of Virginia
Disclosure Statement (Rev. 7/97)

PART I:

(1)	PRINCIPAL: _______________________________________________________________

	In Part I, item 2a, provide name of the individual authorizing your 
	employment as a lobbyist.  The lobbyist filing this statement MAY 
	NOT list his name in item 2a.  THE INDIVIDUAL LISTED IN	PART I, ITEM 
	2A, MUST SIGN THE PRINCIPAL'S STATEMENT.

(2a)	Name: ____________________________________________________________________

(2b)	Permanent Business Address: ______________________________________________

(2c)	Business Telephone: ______________________________________________________

(3)	Provide a list of executive and legislative actions (with as much 
	specificity as possible) for which you lobbied and a description of 
	activities conducted.
	__________________________________________________________________________
	__________________________________________________________________________
	__________________________________________________________________________
	__________________________________________________________________________
	__________________________________________________________________________
	
(4)	INCORPORATED FILINGS:  If you are filing an incorporated disclosure 
	statement, please complete the following:
	
	Individual filing financial information: _________________________________

	Individuals to be included in the filing: ________________________________

	__________________________________________________________________________

(5)	Please indicate which schedules will be attached to your disclosure 
	statement:

	[ ]     Schedule A:  Entertainment Expenses
	[ ]     Schedule B:  Gifts
	[ ]     Schedule C:  Other Expenses	

(6)	EXPENDITURE TOTALS:

a)     ENTERTAINMENT	 				$ ______	
b)     GIFTS 	 					$ ______
	c)     OFFICE EXPENSES 	 			$ ______
	d)     COMMUNICATIONS 	 			$ ______
	e)     PERSONAL LIVING AND TRAVEL EXPENSES	$ ______
	f)     COMPENSATION OF LOBBYISTS 	 	$ ______
	g)     HONORARIA 				$ ______
	h)     REGISTRATION COSTS 	 		$ ______
	i)     OTHER 	 				$ ______

	TOTAL 	 $ ______

PART II:

(1a)	NAME  OF LOBBYIST: _______________________________________________________
	
(1b)	Permanent Business Address: ______________________________________________

(1c)	Business Telephone: ______________________________________________________
	
(2)	As a lobbyist, you are: (check one)

	[ ]     EMPLOYED (on the payroll of the principal)
	[ ]     RETAINED (not on the payroll of the principal, however 		
		compensated)
	[ ]     NOT COMPENSATED (not compensated; expenses may be reimbursed)

(3)	List all lobbyists other than yourself who registered to represent your 
	principal.
	_________________________________________________________________________
	_________________________________________________________________________
	_________________________________________________________________________
	
(4)	If you selected "EMPLOYED" as your answer to Part II, item 2, provide your 
	job title.
	_________________________________________________________________________
	

(5)	If you selected "NOT COMPENSATED" as your answer to Part II, item 2, 
	please indicate why you received no compensation.
	_________________________________________________________________________
	_________________________________________________________________________
	_________________________________________________________________________

PLEASE NOTE:  Some lobbyists are not individually compensated for lobbying 
activities.  This may occur when several members of a firm represent a single 
principal.  The principal, in turn, makes a single payment to the firm.  If this 
describes your situation, do not answer Part II, items 6a and 6b. Instead, 
complete Part III, items 1 and 2.

(6a)	What was the DOLLAR AMOUNT OF YOUR COMPENSATION as a lobbyist?  (If you 
	have job responsibilities other than those involving lobbying, you may 
	have to prorate to determine the part of your salary attributable to 
	your lobbying activities.)  Transfer your answer to this item to Part 
	I, item 6f. 
	_______________________________________________________________________

(6b)	Explain how you arrived at your answer to Part II, item 6a.
	________________________________________________________________________
	________________________________________________________________________
	________________________________________________________________________

PART III:
PLEASE NOTE:  If you answered  Part II, items 6a and 6b, you WILL NOT complete 
this section.

(1)	List all members of your firm, organization, association, corporation, or 
	other entity who furnished lobbying services to your principal.
	_________________________________________________________________________
	_________________________________________________________________________
	
2)	Indicate the total amount paid to your firm, organization, association, 
	corporation or other entity for services rendered.  Transfer your answer 
	to this item to Part I, item 6f.
	_________________________________________________________________________