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PERSONAL FINANCIAL DISCLOSURE STATEMENT

Revised December 417 TIER PERSONAL FINANCIAL DISCLOSURE STATEMENT (ANNUAL) GENERAL INFORMATION v You are required to file a Tier PERSONAL FINANCIAL DISCLOSURE STATEMENT if you are a member (or designee) of a board or commission that has the authority to expend, disburse, or invest $10,000 or more of funds in a fiscal year, members of the State Civil Service Commission and the Louisiana Stadium and Exposition District Board of Commissioners, and the executive director or person holding the equivalent position of each state and statewide retirement system.

Revised December 2016LOUISIANA BOARD OF ETHICS Form 417www.ethics.la.gov Post Office Box 4368 Baton Rouge, Louisiana 70821 This Report Covers Calendar YearORIGINAL REPORTAMENDED REPORT I currently hold an office that would require me to file a Tier 3 Personal Financial Disclosure Statement. Name of Filer (print full name): I have filed for an extension of my federal income tax …

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