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FORM 3A

:

QUARTERLY REPORT OF LOBBYIST ACTIVITY
FOR CONTRACT LOBBYISTS

Each lobbyist must file quarterly reports as follows:

• The report for January 1 – March 31 is due no later than April 15.
• The report for April 1 – June 30 is due no later than July 15.
• The report for July 1 – September 30 is due no later than October 15.
• The report for October 1 – December 31 is due no later than January 15.

Name of Filer: ___________________________________________________________________

I. INFORMATION ABOUT THE FILER

Name each person employed or retained by the filer during the reporting period to contact City
officers.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Report the total payments promised or received from ALL clients:

Total payments promised to the filer from all clients regardless of whether the promised
payments are for services that will be performed within the reporting period:
$______________________________

Total payments received by the filer from all clients during the reporting period regardless
of whether the payments are for services actually performed during the reporting period:
$______________________________

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II. INFORMATION ABOUT THE FILER’S CLIENTS

For each client on whose behalf the filer provided lobbyist services during the reporting period,
report the following information:

Name of client: ____________________________ Telephone:____________________________
Address: ________________________________________________________________________

Total payments promised by the client for lobbying services, including reimbursement for expenses:
$______________

Total payments received from the client, including reimbursement for expenses: $______________

For each payment that was previously reported as a payment promised by (but not actually
received from) the client, report the amount of the payment and the date(s) on which the promised
payment was previously reported. __________________________________________

Describe in detail the lobbyist services provided for which these payments were promised or
received:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Name and title, if applicable, of each City officer and department contacted by the filer on behalf of
the client during the reporting period:

Name Title Department

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

o For multiple clients, please photocopy this sheet and attach additional sheets.

III. REPORT OF ACTIVITY EXPENSES
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Report the total amount of activity expenses incurred by the filer during the reporting period:
$_________________________________

For each activity expense incurred, report the following:
Date of expense: ___________________
Amount of expense: $_______________
Name and official title, if any, of the beneficiary of the activity expense, and the portion of the total
cost of the activity that represents the value of the benefit conferred on the beneficiary:

Name Title Value conferred on Beneficiary
__________________________________________________ $_______________________
__________________________________________________ $_______________________
__________________________________________________ $_______________________

Describe the benefit conferred:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Name the payee of the expense if other than the beneficiary:
________________________________________________________________________________
________________________________________________________________________________

If the activity expense is the salary of an employee of the filer who serves as a City officer, name the
employee, indicate the employee’s official title, and indicate the salary range paid to the employee
during the reporting period by checking off the appropriate box below:

Name Official Title
________________________________________________________________________________

Salary Expense:

o up to $250
o more than $250 but less than or equal to $1,000
o more than $1,000 but less than or equal to $10,000
o more than $10,000

o If additional space is required, check here and attach additional sheets.

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IV. REPORT OF POLITICAL CONTRIBUTIONS

Report the total amount of political contributions made or delivered by the filer, or made by a client
at the behest of the filer, or for which the filer served as an agent or intermediary, during the two
months preceding this filing. $___________

For each political contribution of $100 or more, report the following :

Name the City officer, candidate for City office or committee to which the contribution was made:
_________________________________________________________________________
_______
Amount of the contribution: $____________

Check all that apply: o Filer made the contribution
o Filer delivered the contribution
o A client made the contribution at the behest of the filer
o Filer arranged for the contribution
o Filer served as an agent or intermediary in making the
contribution

If the filer delivered a contribution from another source, arranged or served as an agent or
intermediary in making a contribution for another, or if a client made a contribution at filer’s behest,
identify the true source of the funds:
________________________________________________________________________________

Name the City officer, candidate for City office or committee to which the contribution was made:
_________________________________________________________________________
_______
Amount of the contribution: $____________

Check all that apply: o Filer made the contribution
o Filer delivered the contribution
o A client made the contribution at the behest of the filer
o Filer arranged for the contribution
o Filer served as an agent or intermediary in making the
contribution

If the filer delivered a contribution from another source, arranged or served as an agent or
intermediary in making a contribution for another, or if a client made a contribution at filer’s behest,
identify the true source of the funds:
________________________________________________________________________________

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o If additional space is required, check here and attach additional sheets.

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V. REPORT OF GIFT TICKETS AND ADMISSIONS

For each gift ticket or admission to a political fund-raiser or fundraising event sponsored by a
501(c)(3) organization, given by the filer to a City officer, report the following :

Date of political or charitable fundraising event: __________________________________________
Name of political or charitable fundraising event: _________________________________________
Description of political or charitable fundraising event: ____________________________________
_________________________________________________________________________________

Name and official title of the beneficiary of the gift ticket and/or admission:

Name Official Title
________________________________________________________________________________
________________________________________________________________________________

Date of political or charitable fundraising event: __________________________________________
Name of political or charitable fundraising event: _________________________________________
Description of political or charitable fundraising event: ____________________________________
_________________________________________________________________________________

Name and official title of the beneficiary of the gift ticket and/or admission:

Name Official Title
_________________________________________________________________________________
_________________________________________________________________________________

o If additional space is required, check here and attach additional sheets.

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VI. REPORT OF CITY CONTRACTS

For each City contract awarded to the filer during the reporting period, report the following :

Type of contract awarded:
o rendition of personal services
o furnishing of any material, supplies or equipment to or from the City
o sale or lease of land or buildings to or by the City, or financing of the same

Date City contract was approved: _______________________

Name of City officer and Department that approved the contract:
Name Department
_________________________________________________________________________________

Describe with specificity the subject matter of the City contract:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Type of contract awarded:
o rendition of personal services
o furnishing of any material, supplies or equipment to or from the City
o sale or lease of land or buildings to or by the City, or financing of the same

Date City contract was approved: _______________________

Name of City officer and Department that approved the contract:
Name Department
_________________________________________________________________________________

Describe with specificity the subject matter of the City contract:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

o If additional space is required, check here and attach additional sheets.

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VII. REPORT OF PAYMENTS RECEIVED IN EXCHANGE FOR CAMPAIGN
CONSULTING SERVICES

Report the total payments the filer received from City officers during the reporting period in exchange
for campaign consulting services (as defined in S.F. Admin. Code section 16.541). Such payments
must be reported only if the filer contacted the officer within one year of the date of payment.
$______________

For each City officer from whom a payment was received, report the following :

Name and Department of City officer:__________________________________________________
Name Department
Amount of payment: $___________

Date payment was received by the filer:_________________________________________________

Describe the campaign consulting services provided for which payment was received.

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Name and Department of City officer:__________________________________________________
Name Department
Amount of payment: $___________

Date payment was received by the filer:_________________________________________________

Describe the campaign consulting services provided for which payment was received.

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

o If additional space is required, check here and attach additional sheets.

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VIII. REPORT OF EMPLOYMENT OF CITY OFFICERS OR EMPLOYEES

For each City officer who is employed or retained by the filer at any time during the reporting
period, report the following :

Name of City officer: _______________________________________________________________

Describe the services provided by the City officer to the filer:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Name of City officer: _______________________________________________________________

Describe the services provided by the City officer to the filer:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

For each City officer who is employed or retained by a client of the filer at the behest of the
filer, at any time during the reporting period, report the following:

Name of Client: ___________________________________________________________________

Name of City officer: _______________________________________________________________

Name of Client: ___________________________________________________________________

Name of City officer: _______________________________________________________________

o If additional space is required, check here and attach additional sheets.

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