LAC 52:I.1919
| RETIREMENT SYSTEM FINANCIAL DISCLOSURE REPORT |
| Pursuant to LSA-R.S. 42:1114.2, each person who has or is seeking to obtain a contractual or other business or financial relationship with a state or statewide public retirement system shall file with the Board of Ethics a financial disclosure report semiannually if the person has made expenditures of five hundred dollars or more in a calendar year. Reports disclosing expenditures for retirement officials must be filed by August 15th, covering January 1 through June 30 of the calendar year and by February 15th, covering January 1-December 31 of the calendar year. Although there is no registration requirement under R.S. 42:1114.2, you may be required to register and report under LSAR.S. 49:71 et seq. |
Reports may be mailed or delivered to: Board of Ethics, 2415 Quail Dr., 3rd Floor, Baton Rouge, LA 70808
OR
FOR OFFICE USE ONLYPostmark Date:__________FOR OFFICE USE ONLYPostmark Date:__________Faxed to: (225)7638787 or (225)7638780
REPORT COVERING:
□ JANUARY 1 through JUNE 30, _________ DUE BY AUGUST 15
□ JANUARY 1 through DECEMBER 31, ________ DUE BY FEBRUARY 15
1. Name:
Last First MI
2. Business Address:
Street and No. City State Zip
Mailing Address:
3. Business Phone:
Area Code and Telephone Number
4. Employer:
5. Employer's address:
Street and No. City State Zip
6. Did you make an expenditure exceeding $50 on one occasion for a retirement system official:
From January 1 through June 30? Yes No
From July 1 through December 31? Yes No NA
If the answer to either question in Number 6 above is YES, complete Schedule A and attach.
7. Did you make expenditures exceeding the sum of $250 for a retirement system official:
From January 1 through June 30? Yes No
From July 1 through December 31? Yes No NA
If the answer to either question in Number 7 above is YES, complete Schedule A and attach.
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8. PROVIDE BELOW (a) the name of the state or statewide public retirement system; (b) the aggregate total of all expenditures attributable to the retirement system made during the January 1-June 30 reporting period; (c) the aggregate total of all expenditures attributable to the retirement system made during the July 1-December 31 reporting period when applicable; (d) the aggregate total of all expenditures made in a calendar year attributable to the retirement system.
1) a. Name of Retirement System:
b. Total of all expenditures made January 1 through June 30: $
c. Total of all expenditures made July 1 through December 31:$
(When applicable)
d. Total of all expenditures made during the calendar year: $
2) a. Name of Retirement System:
b. Total of all expenditures made January 1 through June 30: $
c. Total of all expenditures made July 1 through December 31:$
(When applicable)
d. Total of all expenditures made during the calendar year: $
3) a. Name of Retirement System:
b. Total of all expenditures made January 1 through June 30: $
c. Total of all expenditures made July 1 through December 31: $
(When applicable)
d. Total of all expenditures made during the calendar year: $
CERTIFICATION OF ACCURACY
I hereby certify that the information contained herein is true and correct to the best of my knowledge, information, and belief; that all reportable expenditures have been included herein; and that no information required by LSA-R.S. 42:1114.2 has been deliberately omitted.
_________________________________
Signature of Filer
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| SCHEDULE A: EXPENDITURES FOR RETIREMENT SYSTEM OFFICIALS | ||||
| This schedule must be completed if you answered YES to either question 6 or 7on the Retirement System Financial Disclosure Report. If, during the period January 1 through June 30 or the period July 1 through December 31, you made either a) an expenditure for any retirement system official exceeding $50 on any one occasion or b) aggregate expenditures exceeding $250 for any one retirement system official during a reporting period, then you must provide the aggregate total of expenditures made on that individual in that reporting period. NOTE: Report covering July-December is cumulative. You must include reportable expenditures from the first half of the year in Column #3. | ||||
| 1. OFFICIAL'S NAME | 2. NAME OF RETIREMENT SYSTEM | 3. AMOUNT OF EXPENDITURES MADE ON AN OFFICIAL FOR WHOM YOU EITHER SPENT OVER $50 ON ONE OCCASION OR MADE EXPENDITURES EXCEEDING $250 BETWEEN JANUARY 1 AND JUNE 30 | 4. AMOUNT OF EXPENDITURES MADE ON AN OFFICIAL FOR WHOM YOU EITHER SPENT OVER $50 ON ONE OCCASION OR MADE EXPENDITURES EXCEEDING $250 BETWEEN JULY 1 AND DECEMBER 31 | 5. TOTAL OF COLUMNS 3 AND 4 |
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AUTHORITY NOTE: Promulgated in accordance with R.S. 42:1134(A).
HISTORICAL NOTE: Promulgated by the Department of Civil Service, Board of Ethics, LR 30:2696 (December 2004).