FOR OFFICE USE ONLY – REV. 12/26/18
State of Arizona
PRINCIPAL/PUBLIC BODY
Terminate Registration
File with: Arizona Secretary of State
Attention: Election Services Division
1700 W. Washington Street, 7th Fl., Phoenix, AZ 85007
(602) 542-8683 (800) 458-5842 (within Arizona)
Website: www.azsos.gov
PRINCIPAL/PUBLIC BODY TERMINATE REGISTRATION ~ A.R.S. § 41-1232 (C)
Please type or print clearly
.
NAME OF PRINCIPAL/PUBLIC BODY
DESIGNATED LOBBYIST/DESIGNATED PUBLIC LOBBYIST
YOUR TERMINATION CANNOT BE FILED WITHOUT THE PRINCIPAL/PUBLIC BODY’S FINAL
ANNUAL REPORT.
T
he principal or public body hereby terminates its registration for lobbying and the engagement and
authority of any and all lobbyists named in its registration.
STATE OF _________________________ )
)
COUNTY OF ________________________ )
ss
I, the undersigned, being duly sworn state that this Principal / Public Body Registration Termination is complete and that to the
best of my knowledge and belief the information above is true and correct.
______________________________________________
Printed Name of
Designated Lobbyist/Designated Public Lobbyist
____________________________________________
Signature of
Designated Lobbyist/Designated Public Lobbyist
SUBSCRIBED AND SWORN TO (Affirmed) before me on the ____ of ____________________, 20____
_________________________________
_________________________________
(affix seal)
O
OT
RITE IN
HIS
PACE
Office Form S:\Divisions\Elections\Lobbying\LOB_Reporting\Reporting Forms\2019\PPB_termination.doc
