LAC 52:I.1919. Retirement System Financial Disclosure Report

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 LSA-R.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 Faxed to: (225)763-8787 or (225)763-8780 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. Page 1 of _________ 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 Page _________ of _________ 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 Page _________ of _________