File form with:

Secretary of the Senate

Office of Public Records
232 Hart Building
Washington, D. C. 20510

PAYMENTS TO CHARITABLE ORGANIZATIONS

IN LIEU OF HONORARIA
SENATE RULE 35.4(b)

[This form must be provided to the Secretary of the Senate within thirty (30) days after such
designation or recommendation pursuant to rule 35.4(b). verification of registration status for
lobbyists may be obtained from the senate office of public records, 202/224-0758. verification of
registration of an agent of a foreign principal may be obtained from the u.s. department of
Justice, Foreign Agent Registration Unit, 202/514-1231.]

REPORTING INDIVIDUAL'S NAME AND EMPLOYING OFFICE

□ Original □ Amended Version

name/address OF REGISTERED NAME/ADDRESS OF

DATE OF LOBBYIST OR FOREIGN AGENT CHARITABLE ORGANIZATION AMOUNT OF
CONTRIBUTION MAKING CONTRIBUTION DESIGNATED/RECOMMENDED CONTRIBUTION

Signature of Member, Officer, or Employee

Date
SR35.4(b)