Application for Waiver of Late Filing Fee

NYS Joint Commission on Public Ethics
540 Broadway
Albany, New York 12207

Lobbyist/Client/Public Corporation (Name):

Report Charged with late Filing Fee:

Year:

Check Here if Report Charged with Late Filing Fee is an Amendment:

Client (Name) (if applicable):

Amount of Late Filing Fee:

Justification for Waiver:

I declare under penalty of perjury that the information contained in this Application is true, correct and complete to the best of my knowledge and belief.

Signature of Responsible Person:

E-mail of Responsible Person:

Date:

Print/Type Name: