Nebraska Legislature - Lobbyist Reporting Application

FORM
A

NEBRASKA LEGISLATURE
APPLICATION FOR REGISTRATION AS A LOBBYIST

Jan 17, 2020

Clerk of the Legislature
Room 2014, State Capitol
PO Box 94604
Lincoln, NE 68509-4604
Phone: (402) 471-2608

For Calendar Year of:

Amended Registration

Lobbyist Registration Fee:
{49-1480.01}

Compensated

$200.00

(If you are a salaried employee of your principal, you are a compensated lobbyist.)

Not Compensated

$15.00

(File a Form E for quarterly report exemption. You are not exempt from the Form D Activity Report.)

PLEASE FILL IN ALL BLANKS

LOBBYIST {49-1480(1)}

Name

Kissel Kohout ES Associates, LLC

Office Address (Street, Box, or Route)

301 S. 13th Street, Suite 400

Permanent Residence (Street, Box, or Route)

City

Lincoln

State

Zip

68508

City

State

Zip

Office Phone

(402) 476-1188

Home Phone

Email Address

jkohout@kisselkohoutes.com

PRINCIPAL {49-1480(2)}

Name

Autism Center of Nebraska

Office Phone

(402) 315-1000

Office Address (Street, Box, or Route)

9012 Q Street

Official to Whom Lobbyist is Accountable

Brett Samson

City

Omaha

State

Zip

68127

Nature of Business {49-1480(3)}

Service Provider

AMOUNTS GIVEN or to be given to lobbyist as compensation or reimbursement of lobbying: {49-1480(3)}. Please state the basis for your compensation.
5,000.00 Per Year

IDENTIFICATION of MATTERS on which principal or lobbyist expects to lobby: {49-1480(5)} Issues relating to developmental disabilities

Description of industry, trade, profession, or interests and groups represented by the principal:

Names and addresses of principal's officers:

GIVE NAME and ADDRESS of any OFFICIAL in the Legislative or Executive Branch and of any members of any such official's staff or immediate family who is employed by you or by anyone acting on your behalf: {49-1480(8)}

I certify that all information presented in this form is accurate to the best of my knowledge.

Kissel Kohout ES Associates, LLC

Lobbyist Name

Jan 17, 2020

Date