Spreadsheet For Expenses 40664 | 2021 Prescription Drug Marketing Costs (6)

Partial file snippet.

Sheet 1: Company Information

	
	
	
		Fill out electronically, print, and sign this "Company Information" sheet to authenticate the submission of the required annual report. This sheet should be submitted with the required filing fee of $5,000 made payable to D.C. Treasurer.
		
	
		

		

	
	
		Please enter the requested information in the space provided. For more information, refer to instructions in the fourth sheet.
		
	
		

		

	
	
		Manufacturer/Labeler Company
		

	
	
		Company Name:
		

	
	
		Company Address:
		

	
	
		Company City:
		

	
	
		Company State:
		

	
	
		Company Zip:
		

	
	
		Company Email:
		

	
	
		Company Phone:
		

	
	
		Company Fax:
		

	
	
		

		

	
	
		Individual Responsible for Submission
Pursuant to 22 DCMR 1801.5 "The individual identified… shall be a member of senior management or senior level company official within the manufacturer's or labeler's company or corporate structure" 
		
	
		Responsible Individual Name:
		

	
	
		Responsible Individual Title:
		

	
	
		Responsible Individual Address:
		

	
	
		Responsible Individual City:
		

	
	
		Responsible Individual State:
		

	
	
		Responsible Individual Zip:
		

	
	
		Responsible Individual Email:
		

	
	
		Responsible Individual Phone:
		

	
	
		Responsible Individual Fax:
		

	
	
		

		

	
	
		2021 Marketing Expenses
		
	
		Total Gift Expenses
		

	
	
		Total Advertising Expenses
		

	
	
		Total Aggregate Cost
		

	
	
		Total Marketing Expenses
		$0.00
	
	
		

		

	
	
		

		

	
	
		Pursuant to the District of Columbia Municipal Regulation 1801.4(c), a wet signature is to be submitted in conjunction with the filing of this report.
		
	
		

		

	
	
		I certify, under penalty of law, the information contained in this report is true and accurate to the best of my knowledge. I understand that providing false information or omission of information is unlawful. 

		
	
		

		

	
	
		

		

	
	
		

		

	
	
		Submission Date
		

	
	
		

		

	
	
		

		

	
	
		Signature of Individual Responsible
		

	
	
		

		

	
	
		

		

	
	
		Check Number Submitted
		

	



Sheet 2: Gift Expenses

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
		Payment Date
		Non-Individual Recipient
		Recipient Last Name
		Recipient First Name
		Recipient MI
		
		Accepted values: APN/NP*, RN/LPN, PharmD, RPH, ND, PA*, DDS*, DO*, DPM*, MD*, OD*, DVM, Other
		Recipient Credentials
		Other Credentials
		Recipient Affiliated Facility
		
		Accepted values: Clinic, Dentist*, Hospital*, Medical Education or Communication Company, Medical Staff, Nonprofit Organization, Nurse, Nurse Practitioner/Advanced Practice Nurse, University, Pharmacist, Physician*, Physician Assistant, Psychologist, Social Worker, Technician, Other 
		Recipient Type
		Other Type
		
		Accepted values: Consulting Fee, Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program, Honoraria, Gift, Entertainment, Food and Beverage, Travel and Lodging, Education, Charitable Contribution, Royalty or License, Current or prospective ownership or investment interest, Compensation for serving as faculty or as a speaker for a non-accredited and non-certified continuing education program, Compensation for serving as faculty or as a speaker for an accredited or certified continuing education program, Grant, Space Rental or Facility Fees, Other
		Nature of Payment
		Other Nature
		
		Accepted Values: Cash or Cash Equivalent, In-kind Items and Services; Stock, stock options, or any other ownership interest; Dividend, profit or other return on investment, Other
		Form of Payment
		Other Form
		
		Accepted values: Consulting, Education, Marketing, Donation, Other 

		Primary Purpose
		Other Primary Purpose
		
		Accepted values:
None, Consulting, Education, Marketing, Donation, Other
		Secondary Purpose
		Other Secondary Purpose
		Value
		
		Accepted values:
No, Yes
		Trade Secret?
		Trade Secret Explanation
		
		Accepted values:
No, Yes

		Re-submission?
		Original Submission Date
		Resubmission Description
	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	



Sheet 3: Advertising Expenses

	
	
	
	
	
	
	
	
	
	
	
	
		Activity Date
		
		Accepted values: Direct-to-Consumer Advertisement Production, Direct-to-Consumer Advertisement Placement, Other Advertisement Production, Other Advertisement Placement, Market Research, Other Promotional Activity

		Type of Activity
		
		Accepted values: Conference or Other Event, Direct Mail, Internet/Email, Medical Journal, Newspaper/Magazine, Patient Materials, Radio, TV/Video, Other Printed Material, Other

		Medium Type
		Medium Name
		Product Marketed
		Target Audience
		Cost of Activity
		
		Accepted values:
No, Yes

		Trade Secret?
		Trade Secret Explanation
		
		Accepted values:
No, Yes

		Re-submission?
		Original Submission Date
		Resubmission Description

The words contained in this file might help you see if this file matches what you are looking for:

...Sheet company information fill out electronically print and sign this quot to authenticate the submission of required annual report should be submitted with filing fee made payable dc treasurer please enter requested in space provided for more refer instructions fourth manufacturerlabeler name address city state zip email phone fax individual responsible submissionpursuant dcmr identified hellip shall a member senior management or level official within manufacturer s labeler corporate structure title marketing expenses total gift advertising aggregate cost pursuant district columbia municipal regulation c wet signature is conjunction i certify under penalty law contained true accurate best my knowledge understand that providing false omission unlawful date check number payment nonindividual recipient last first mi accepted values apnnp rnlpn pharmd rph nd pa dds do dpm md od dvm other credentials affiliated facility clinic dentist hospital medical education communication staff nonprofi...

Activity Date	Accepted values: Direct-to-Consumer Advertisement Production, Direct-to-Consumer Advertisement Placement, Other Advertisement Production, Other Advertisement Placement, Market Research, Other Promotional Activity Type of Activity	Accepted values: Conference or Other Event, Direct Mail, Internet/Email, Medical Journal, Newspaper/Magazine, Patient Materials, Radio, TV/Video, Other Printed Material, Other Medium Type	Medium Name	Product Marketed	Target Audience	Cost of Activity	Accepted values: No, Yes Trade Secret?	Trade Secret Explanation	Accepted values: No, Yes Re-submission?	Original Submission Date	Resubmission Description

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Fill out electronically, print, and sign this "Company Information" sheet to authenticate the submission of the required annual report. This sheet should be submitted with the required filing fee of $5,000 made payable to D.C. Treasurer.

Please enter the requested information in the space provided. For more information, refer to instructions in the fourth sheet.

Manufacturer/Labeler Company
Company Name:
Company Address:
Company City:
Company State:
Company Zip:
Company Email:
Company Phone:
Company Fax:

Individual Responsible for Submission Pursuant to 22 DCMR 1801.5 "The individual identified… shall be a member of senior management or senior level company official within the manufacturer's or labeler's company or corporate structure"
Responsible Individual Name:
Responsible Individual Title:
Responsible Individual Address:
Responsible Individual City:
Responsible Individual State:
Responsible Individual Zip:
Responsible Individual Email:
Responsible Individual Phone:
Responsible Individual Fax:

2021 Marketing Expenses
Total Gift Expenses
Total Advertising Expenses
Total Aggregate Cost
Total Marketing Expenses	$0.00


Pursuant to the District of Columbia Municipal Regulation 1801.4(c), a wet signature is to be submitted in conjunction with the filing of this report.

I certify, under penalty of law, the information contained in this report is true and accurate to the best of my knowledge. I understand that providing false information or omission of information is unlawful.



Submission Date


Signature of Individual Responsible


Check Number Submitted

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