Nebraska Legislature - Lobbyist Reporting Application

FORM
A

NEBRASKA LEGISLATURE
APPLICATION FOR REGISTRATION AS A LOBBYIST

Jan 8, 2024

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

Kemp, Carissa

Office Address (Street, Box, or Route)

3720 N Collister Drive

Permanent Residence (Street, Box, or Route)

3720 N Collister Drive

City

Boise

State

Zip

83703

City

Boise

State

Zip

83703

Office Phone

(715) 573-1234

Home Phone

(715) 573-1234

Email Address

ckemp@diabetes.org

PRINCIPAL {49-1480(2)}

Name

American Diabetes Association

Office Phone

(715) 573-1234

Office Address (Street, Box, or Route)

3720 N Collister Drive

Official to Whom Lobbyist is Accountable

American Diabetes Association

City

Boise

State

Zip

83703

Nature of Business {49-1480(3)}

American Diabetes Association

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

IDENTIFICATION of MATTERS on which principal or lobbyist expects to lobby: {49-1480(5)} Healthcare, insurance, diabetes care

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

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.

Carissa Kemp

Lobbyist Name

Jan 8, 2024

Date