La. Admin. Code tit. 52 § I-1919

Current through Register Vol. 50, No. 11, November 20, 2024

Section 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

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

FOR OFFICE USE ONLY

Postmark Date:__________

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.

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.

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: $_______________________________

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: $ ________________________________

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

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

La. Admin. Code tit. 52, § I-1919

Promulgated by the Department of Civil Service, Board of Ethics, LR 30:2696 (December 2004).

AUTHORITY NOTE: Promulgated in accordance with R.S. 42:1134(A).