13L LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 11.5.3.2 PERSONAL FINANCIAL DISCLOSURE STATEMENT (ANNUAL) I currently hold an of?ce that would require me to ?le a Tier 2.1, or Tier 3 Personal Financial Disclosure Statement. As such, I have completed SCHEDULE D. REPORT This Report Covers Calendar Year: 2015 AMENDED REPORT i? FINAL REPORT (WHERE TERM ENDS IN JANUARY JANUARY 1 THROUGH JANUARY 1) A final reports must be filed on or before May 15 of the year in which your service to that Of?ce ends. Refer to the sheet of this form to determine eligibility. HELD: State Representative MM 12, M4324 (pic/?1) NAME OF FILER (print full name): EddieJ, Lambert Mailing Address P. 0- Box 88 City, State, Zip: Gonzales, LA 70707 NAME OF applicable](print full name): - M- Lambert Spouse's Occupation: Parish Court JUdge 00 Spouse's Principal Business Address: 323 5- Irma Blvd. 4/ . City, State, Zip: Gonzales, LA 70737 CHECK ALL THAT APPLY r?o I have filed my state income tax return for the previous year. I have filed for an extension of my state income tax return for the previous year. I have filed my federal income tax return for the previous year. i? I have filed for an extension of my federal income tax return for the previous year. 7 I have filed for an extension of my federal income tax return for the previous year AND I am requesting an extension in filing my Tier 2 Personal Financial Disclosure. CERTIFICATE OF ACCURACY - beSt of my knowledge, information, and belief. 64w 1 6 Sworn to and subscribewmre me this day of 20?. (Macaw . . a Wlicmrintname) Notary Public (signature) ?a ?nal Date Commission Expires A - Revised October 201 4 Form 416A ethics. Ia. gov LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule A: Employment Information in Check if not applicable RiFiler i? Spouse FFull-Time Part?Time Name of Employer: Louisiana House of Representatives Job Title: Representative Legislator Job Description: lWFiler i3? Full?Time Part-Time Name of Employer: State of Louisiana lob Title: Ascension Parish Court Judge Judge Job Description: {?Filer F'Spouse imrFull-Time V'Part?Time Name of Employer: Job Title: Job Description: ViFiler Spouse i" Full-Time i? Part-Time Name of Employer: Job Title: Job Description: V'Filer i? Spouse i? Full-Time i? Part?Time Name of Employer: Job Title: Job Description: You are required to disclose employment information related to both you and your spouse (if applicable). List the name of the employer; the title of the position; a brief description of the job; and disclosure as to whether the position is full?time or part-time. Self~employment information is reported on Schedule B. Revised October 201 4 Form 41 6A ethics. la.gov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule B: Positions - Business in Check if not applicable l3?? Filer Spouse lw Both Amount of Interest (amount exceeds 100 Name of Business; Eddie J. Lambert, Attorney at Law Address; P. O. Box 88 City, State, Zip: Gonzales, LA 70707 Business Description: Law Practice Nature of Association: Sole Proprietor Filer if? Spouse if" Both Amount of Interest [amount exceeds 100 Name of Business: Eddie J. Lambert Address; P. O. Box 88 City, State, Zip: Gonzales, LA 70707 Business Description: Commercial Fisherman 8: Alligator Hunter Nature of Association: Sole Proprietor Filer V'Spouse 17 Both Amount of Interest (amount exceeds 100 Name of Business: Lori Marie, LLC Address: P. O. Box 88 City, State, Zip: Gonzales, LA 70707 Business Description; General investment Business Nature of Association: Owner You are required to complete SCHEDULE if you or your spouse is a director, officer, stockholder, owner, partner, member, or trustee of a business AND if you or your spouse (either individually or collectively) owns an interest in a business which exceeds 10%. "Business? means any corporation, partnership, limited liability company, sole proprietorship, firm, enterprise, franchise, association, business, organization, self-employed individuai, holding company, trust, or any other legal entity or person. Revised October 2014 Form 41 6A gov lw Check if not applicable LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule B: Positions Business Filer Spouse i? Both Amount of Interest (amount exceeds 3333 Name of Business: VCG Partnership Address; 1000 Shirley Ave. City, State, Zip: Gonzales, LA 70737 Business Description: Land Ownership Nature of Association: Partnership Filer l3? Spouse lw Both Amount Of Interest [amount exceeds 20 Name of Business; Ashland RV Park, LLC Address; 1125 Grand Gulf Rd. City, State, Zip: Port Gibson, MS 39150 Business Description: RV Park Nature of Association: LLC V7 Filer lm?fSpouse l3? Both Amount of Interest [amount exceeds 100 Name of Business: Atchafalaya Swamp Adventures Address: P. O. Box 88 City, State, Zip: Gonzales, LA 70707 Business Description: Guide Services Nature of Association: LLC business which exceeds 10%. Revised October 201 4 Form 41 6A You are required to complete SCHEDULE if you or your spouse is a director, officer, stockholder, owner, partner, member, or trustee of a business AND if you or your spouse (either individually or collectively) owns an interest in a "Business? means any corporation, partnership, limited liability company, sole proprietorship, firm, enterprise, franchise, association, business, organization, self-employed individual, holding company, trust, or any other legal entity or person. LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 SChEdule B: Positions - Business Check if not applicable Filer i? Spouse 53' Both Amount of Interest [amount exceeds 100 Name of Business; Pierre Part Cajun Retreat Address: O. Box 88 City, State, Zip: Gonzales, LA 70707 Business Description: Cabin Rentals Nature of Association: LLC l? Filer Spouse i? Both Amount of Interest [amount exceeds Name of Business: Address: City, State, Zip: Business Description: Nature of Association: Filer l? Spouse l" Both Amount of Interest [amount exceeds 33.33 Name of Business; Atchafalaya Alligator Hunts, LLC Address: 124 5. Bay Rd. City, State, Zip: Pierre Part, LA 70339 Business Description; Alligator Hunting Guide Services Nature of Association: LLC You are required to complete SCHEDULE if you or your spouse is a director, officer, stockholder, owner, partner, member, or trustee of a business AND if you or your spouse (either individually or collectively) owns an interest in a business which exceeds 10%. ?Business? means any corporation, partnership, limited liability company, sole proprietorship, firm, enterprise, franchise, association, business, organization, self-employed individual, holding company, trust, or any other legal entity or person. Revised October 2014 Form 416A LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule C: Positions - Nonprofit #7 Check if not applicable Filer in? Spouse Name of Organization: Address: City, State, Zip: Nature of Association: Description of Organization: Filer Ff Spouse Name of Organization: . Address: City, State, Zip: Nature of Association: Description of Organization: Filer Spouse Name of Organization: Address: City, State, Zip: Nature of Association: Description of Organization: *You are required to complete SCHEDULE if you or your spouse is a director or of?cer of a nonprofit organization. Revised October 2014 Form 41 6A LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule D: OtherOffices/Positions Held Check if not applicable Name of Office/Position: Name of Office/ Position: Name of Office Position: Name of Office/ Position: Name of Office Position: Name of Office Position: Name of Office Position: Name of Office/Position: Name of Office Position: You are required to complete SCHEDULE if you hold any other office or position which would require you to file a personal ?nancial disclosure statement under La. R.S. 42:1124.2.1 or 42:11243. Revised October 201 4 Form 416A ethics. lagov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule E: lmmovable Property Check if not applicable (where the value of the interest in the parcel exceeds $2,000) Filer i? Spouse i3?? Both Location of Property: State: La Parish/County: Ascension Description of Property: Home Value of the Interest in the Parcel: Category I [less than $5,000) l"w Category II f" Category {52? Category IV (more than $100,000) ii; Filer FSpouse 3W Both Location of Property: State: La Parish County: Ascension Description of Property: Rental Residential property Value of the Interest in the Parcel: Category I [less than $5,000] Category 11 l? Category Category IV (more than $100,000] i" Filer i? Spouse Both Location of Property: State: La Parish County: Ascension Description of Property: Rental Residential Property Value of the Interest in the Parcel: l? Category I (iess than $5,000] 1? Category Ii l" Category Category IV (more than $100,000) You are required to. disclose the location by state and parish/county. You are required to provide a brief description of the immovable property and its fair market value or use value (determined by the assessor for purposes of ad valorem taxes.) Revised October 2014 Form 41 6A LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule E: lmmovable Property Check if not applicable (where the value of the interest in the parcel exceeds $2,000) Filer i? Spouse i3? Both Location of Property: State: La Parish County: Assumption Description of Property: Rental Residential Property Value of the Interest in the Parcel: Category I (less than $5,000) i? Category II Category Category IV (more than $100,000) Filer Spouse Both Location of Property: State: La Parish/County: Ascension Description of Property: Of?ce Value of the Interest in the Parcel: i? Categoryi [less than $5,000) i? Category II If? Category Category IV [more than $100,000) Filer Spouse 33? Both Location of Property: State: La Parish County: Assumption Description of Property: Camp Value of the Interest in the Parcel: Category 1 [less than $5,000] Category II l? Category Category IV (more than $100,000) You are required to disclose the location by state and parish/county. You are required to provide a brief description of the immovable property and its fair market value or use value (determined by the assessor for purposes of ad valorem taxes.) Revised October 2014 Form 41 6A LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 SChEdule E: Immovable Property Check if not applicable (where the value of the interest in the parcel exceeds $2,000) Filer l" Spouse l5? Both Location of Property: State: La Parish County: Assumption Description of Property: Vacant lot Value of the Interest in the Parcel: Category 1 [less than $5,000) i? Category II Category if Category IV [more than $100,000] l? Filer l? Spouse Both Location of Property: State: La Parish County: Assumption Description of Property: Rental property (cabins) Value of the Interest in the Parcel: Category 1 (less than $5,000) Category II Category 33? Category IV [more than $100,000} lm Filer {SESpouse Both Location of Property: State: Mississippi Parish County: Claiborne Description of Property: Timberland Value of the Interest in the Parcel: l" Categoryl [less than $5,000) 1? Category II 1? Category 13? Category IV (more than $100,000) You are required to disclose the location by state and parish/county. You are required to provide a brief description of the immovable property and its fair market value or use value (determined by the assessor for purposes of ad valorem taxes.) Revised October 201 4 Form 41 6A LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule F: Income from the State, Political i? Check if not applicable Subdivisions, and/or Gaming Interests if" Filer RiSpouse TT'BusinessMhere amount of interest exceeds 10%) Type of Income: i3? State Political Subdivision i" Gaming Interest Name of Business?f applicable): Judicial Branch of Louisiana Name of lnCome Source: same Address; 400 Royal St., Suite 1 190 City, State, Zip: New Orleans, LA 70130 Amount of Income (exact dollar amount): 86,510.64 Filer Spouse l? Business[where amount of interest exceeds 10%) Type of Income: l? State {33 Political Subdivision i" Gaming Interest Name of Business?f applicable): Ascension Parish Court JEF Name of Income Source: same Address: 828 S. Irma Blvd, bldg. 2 City, State, Zip: Gonzales, LA 70737 Amount of Income [exact dollar amount): 429063-12 l? Filer l3? Spouse 1 l? Business[whereamount of interest exceeds 10%) Type of Income: WState RPolitical Subdivision if? Gaming Interest Name of Business?f applicable): Parish 0f Ascension Name of Income Source: same Address: P. O. Box 2392 City, State, Zip: Gonzales, LA 70707 Amount of Income [exact dollar amount): 629232 You are required to complete SCHEDULE if you or your spouse received income (includes any income from public source such as employment income, retirement, etc.) from the State, any political subdivision, and/or a gaming interest OR if a business in which you or your spouse owns an interest which exceeds 10% (either individually or collectively) received income from the aforementioned sources. "Income? (for a business) means gross income less costs of goods sold, and operating expenses. ?Income? (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. The definitions for (and examples of) political subdivision, gaming interest, and business are found in the instructidns Section of this form. Revised October 2014 Form 41 6A eth ics. Ia. gov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule F: Income from the State, Political i7 Check if not applicable Subdivisions, and/or Gaming Interests 1 Filer i3? Spouse W?Busines?where amount of interest exceeds 10%) Type of Income: TState Political Subdivision i? Gaming Interest Name of Business?f applicable): City Of Donaldsonville Name of Income Source: same Address: P. O. Box 470 City, State, Zip: Donaldsonville, LA 70346 Amount of Income [exact dollar amount): 7053.64 Filer i3? Spouse 0 in" Business[where amount ofinterest exceeds 10%] Type oflncome: State RPolitical Subdivision i? Gaming Interest Name of Business?f applicable): City 0? Gonzales A Name of Income Source: same Address: 120 S. Irma Blvd. City, State, Zip: Gonzales, LA 70737 Amount of Income (exact dollar amount): 6292.32 lw Filer Spouse i? Business(where amount of interest exceeds 10%) Type Of Income: F'State 53 Political Subdivision i? Gaming Interest Name of Business?f applicable): Town 01? Sorrento Name of Income Source: same Address: P. O. Box 65 City, State, Zip: Sorrento, LA 70778 Amount Of Income (exact dollar amount): 2927-04 You are required to complete SCHEDULE if you or your spouse received income (includes any income from public source such as employment income, retirement, etc.) from the State, any political subdivision, and/or a gaming interest OR if a business in which you or your spouse owns an interest which exceeds 10% (either individually or collectively) received income from the aforementioned sources. ?Income" (for a business) means gross income less costs of goods sold, and operating expenses. ?Income" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. The definitions for (and examples of) political subdivision, gaming interest, and business are found in the Instructions Section of this form. Revised October 201 4 Form 41 6A 161.9011 LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule F: Income from the State, Political Check ifnot applicable Subdivisions, and/or Gaming Interests Filer l? Spouse l? Business[where amount of interest exceeds 10%) Type of Income: VState RPolitical Subdivision Name of Business?f applicable); Louisiana House of Representatives Name of Income Source: same Address: P. O. BOX 94062 City, State, Zip: Baton Rouge, LA 70804 Amount of Income [exact dollar amount): 24964-90 l? Filer l3?? Spouse i? Business[where amount of interest exceeds 10%) Type of Income: fzState l3? Political Subdivision 3- Gaming Interest Name of Business?f applicable): Name of Income Source: Address: City, State, Zip: Amount of Income (exact dollar amount): l" Filer WISpouse amount of interest exceeds 10%) Type of Income: iT'State Political Subdivision Gaming Interest Name of Business?f applicable): n/a Name of Income Source: Address: City, State, Zip: Amount of Income (exact dollar amount]: You are required to complete SCHEDULE if you or your spouse received income (includes any income from public source such as employment income, retirement, etc.) from the State, any political subdivision, and/or a gaming interest OR if a business in which you or your spouse owns an interest which exceeds 10% (either individually or collectively) received income from the aforementioned sources. ?Income" (for a business) means gross income less costs of goods sold, and operating expenses. ?Income" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. The definitions for (and examples of) political subdivision, gaming interest, and business are found in the Instructions Section of this form. Revised October 201 4 Form 41 6A gov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule G: Income Received from Employment Check if not applicable i? Filer f? Spouse Full?time i? Part-time Name of Employer: Address: City, State, Zip: Nature of services [pursuant to such employment]: Amount of Income: i? Category I (less than $5,000) Category II Category Category 1V [more than $100,000) if? Filer i? Spouse inull-time i? Part-time Name of Employer: Address: City, State, Zip: Nature of services (pursuant to such employment): Amount of Income: Categoryl (less than $5,000) Category II 5? Category i? Category IV (more than $100,000) Filer if? Spouse i" Full-time i? Part?time Name of Employer: Address: City, State, Zip: Nature of services (pursuant to such employment): Amount of Income: Category I [less than $5,000) a? Category II l? Category 5W . Category IV (more than$100,000] You are required to complete SCHEDULE to disclose the income received by you or your spouse for each full-time or part-time employment position held. ?Income? (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. income that is reported on SCHEDULE does not have to be restated on SCHEDULE G. Income received through self-employment is reported on SCHEDULE H, unless it is reported on Schedule F. Revised October 201 4 Form 41 6A la. gov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedu le H: Income Received FrOm Business Check if not applicable AGGREGATE AMOUNT OF INCOME RECEIVED FROM BUSINESS: Category 1 (less than $5,000) if? Category II Category Category IV (more than $100,000) Filer Spouse Name of Business: Ashland RV Park, LLC Address; 1125 Grand Gulf Rd. City, State, Zip: Port Gibson, MS 39150 Nature of services rendered or reason income was received: RV Park l3? Filer R'Spouse Name of Business: Pierre Part Cajun Retreat Address: Po. Box 88 City, State, Zip: Gonzales, LA 70707 Nature of services rendered or reason income was received: Cabin Rentals l3? Filer l? Spouse Name of Business; Eddie J. Lambert, Attorney at Law Address: P. O. Box 88 City, State, Zip: Gonzales, LA 70707 Nature of services rendered or reason income was received: Law Practice 5? Filer WSpouse Name of Business; Eddie J. Lambert, Commercial Fishing Alligator Hunter Address: P. O. Box 88 City, State, Zip; Gonzales, LA 70707 Nature of services rendered or reason income was received: Fishing and alligator hunting You are required to complete SCHEDULE if you or your spouse received income from a business. ?Income" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. Income reported on SCHEDULE or does not have to be restated on SCHEDULE H. Income received through self-employment is reported on SCHEDULE H. ?Business? means any corporation, partnership, limited liability company, sole proprietorship, firm, enterprise, franchise, association, business, organization, self-employed individual, holding company, trust, or any other legal entity or person. Revised October 2014 Form 416A LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule I: Other Income Check if not applicable (any other income that exceeds $1,000) f? Filer EZSpouse Description of Income: CRP Annual Rental from U. S. Department of Agriculture FSA Nature of services rendered or reason income was received: CRP Annual Rental for property in Mississippi Amount of Income: 52 Categoryl (less than $5,000) i? Category II i? Category ii? Category IV (more than $100,000) {ZFiler l3? Spouse Description of Income: Rental Property Nature of services rendered or reason income was received: Rental property Amount of Income; l? Categoryl (less than $5,000} l? Category II Category Category IV (more than $100,000) Filer l? Spouse Description of Income: Nature of services rendered or reason income was received: Amount of Income; Category I (less than $5,000) 25? Category II l? Category Category IV (more than $100,000) You are required to complete SCHEDULE I if you or your spouse received any other type of income (includes any income from private source such as rental income, federal retirement, etc.) that exceeded $1,000. ?Income" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. You are not required to report income that is derived from child support and alimony payments contained in a court order, or from disability payments from any source. Income that is reported on SCHEDULE F, G, or does not have to be restated on SCHEDULE I. Income from retirement accounts not reported on Schedule should be included on Schedule I. Revised October 201 4 Form 41 6A LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule Investment Holdings l? Check if not applicable (an investment holding that exceeds $5,000) Filer l? Spouse 5? Both Name of Security: Carty Co./Pershing Group Description of Security: tax free bonds i? Filer lw Spouse Both Name of Security: Description of Security: i? Filer WSpouse l? Both Name of Security: Description of Security: You are required to complete SCHEDULE if you or your spouse holds investment securities where each investment security has a value that exceeds $5,000. - You are not required to disclose variable annuities, variable life insurance, variable universal life insurance, whole life insurance, any other life insurance product, mutual funds, education investment accounts, retirement investment accounts, government bonds, and cash/cash equivalent investments. You are not required to disclose information concerning any property held and administered for any person other than you or your spouse under a trust, tutorship, curatorship, or other custodial instrument. Revised October 2014 Form 41 6A ethics. lagov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule K: Transactions Check if not applicable (a transaction that exceeds $5,000) i?Filer Spouse F?Both Transaction Date: Description of Transaction: Amount of Transaction: if Categorylaessthanssnom 1? Category i? Category II in? Category IV [more than $100,000] F'Filer V?Spouse TBoth Transaction Date: Description of Transaction: Amount of Transaction: if? Categoryl [lessthan $5,000] r" Category Category II Category IV (more than $100,000) Filer i? Spouse 3? Both Transaction Date: Description of Transaction: Amount of Transaction: Category 1 [less than $5,000) TM Category i? Category II i? Category IV (more than $100,000) You are required to complete SCHEDULE if you or your spouse purchased or sold any immovable property, personally owned tax credit certificates, stocks, bonds, or commodities futures including any option to acquire or dispose of any immovabie preperty or of any personally owned tax credit certificates, stocks, bonds, or commodities futures (when the value of the transaction exceeded $5,000 in the previous calendar year). You are not required to report variable annuities, variable life insurance, variable universal life insurance, whole life insurance, any other life insurance product, mutual funds, education investment accounts, retirement investment accounts, government bonds, cash or cash equivalent investments. Revised October 201 4 Form 41 6A Iagov LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule L: Liabilities if Check if not applicable (a liability that exceeds $10,000) Filer if? Spouse Name of Creditor: Address: City, State, Zip: Name of Guarantor (If applicable): if? Filer Spouse Name of Creditor: Address: City, State, Zip: Name of Guarantor (If applicable): l? Filer Il??Spouse Name of Creditor: Address: City, State, Zip: Name of Guarantor (If applicable): Filer WSpouse Name of Creditor: Address: City, State, Zip: Name of Guarantor (Ifapplicable): *You are required to complete SCHEDULE if you or your spouse owes any liability which exceeds $10,000 on the last day of the reporting period. *You are not required to disclose any loan secured by movable property, if such loan does not exceed the purchase price of the movable property which secures the loan. *You are not required to disclose any liability, secured or unsecured, which is guaranteed by you or your spouse for a business in which you or your spouse owns any interest, provided that the liability is in the name of the business and, if the liability is a loan, that you or your spouse does not use proceeds from the loan for personal use unrelated to business. *You are not required to disclose any loan by a licensed financial institution which loans money in the ordinary course of business. You are not required to disclose any liability resulting from a consumer credit transaction as defined in R.S. 9:3516l13). *You are not required to disclose any loan from an immediate family member, unless such family member is a registered lobbyist, or his principal or employer is a registered lobbyist, or he employs or is a principal of a registered lobbyist, or unless such family member has a contract with the State. *"Consumer Credit Transaction" in R.S. means a consumer loan or a consumer credit sale but does not include a motor vehicle credit transaction made pursuant to R.S. 6:969.1 et seq. Revised October 2014 Form 41 6A gov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule M: Positions - Business (to be completed by members of the Ethics Adjudicatory Board and Check if not applicable Ethics Board, and the administrator of the Ethics Administration) Ff Filer l" Spouse l? Both Name of Business: Address: City, State, Zip: Business Description: Nature of Association: Amount of Interest: Filer F?Spouse l" Both Name of Business: Address: City, State, Zip: Business Description: Nature of Association: Amount of Interest: if? Filer if? Spouse l? Both Name of Business: Address: City, State, Zip: Business Description: Nature of Association: Amount of Interest: You are required to complete SCHEDULE if you are a member of the Ethics Adjudicatory Board; a member of the Board of Ethics; or if you serve as administrator of the Ethics Administration. You are required to disclose information related to ownership interest in a business regardless of the percentage of ownership. "Business" means any corporation, partnership, sole proprietorship, firm, enterprise, franchise, association, business, organization, self-employed individual, holding company, trust, or any other legal entity or person. Information disclosed on SCHEDULE does not have to be restated on SCHEDULE M. Revised October 2014 Form 41 6A LOUISIANA BOARD OF ETHICS Post Office Box 43 68 Baton Rouge, Louisiana 70821 Schedule N: Income from the State (to be completed by members of the Ethics Adjudicatory Board and Ethics Board, and the administrator of the Ethics Administration) l" Filer F?ESpouse Business Type of Income: Political Subdivision Name of Business [if applicable): Name of Income Source: Address: City, State, Zip: Amount of Income [exact dollar amount): i? Filer Spouse l? Business Type of Income: l? State T?Political Subdivision Name of Business [if applicable): Name of Income Source: Address: City, State, Zip: Amount of Income (exact dollar amount): VSpouse F'Business Type of Income: I'm-State F?Political Subdivision Name of Business (if applicable): Name of Income Source: Address: City, State, Zip: Amount of Income (exact dollar amount): You are required to complete SCHEDULE if. you are a member of the Ethics Adjudicatory Board; a member of the Board of Ethics; or if you serve as administrator of the Ethics Administration. You are required to disclose all income received by a business in which you or your spouse received regardless of the percentage of ownership in the business. "Income" (for a business) means gross income less costs of goods sold, and operating expenses. "Income" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. information disclosed on SCHEDULE does not have to be restated on SCHEDULE N. Revised October 201 4 Form 41 6A ethics. Ia. gov LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule 0: Income from a Governmental Entity (to be completed by members of the Ethics Adjudicatory Board and 53: Check if not applicable Ethics Board, and the administrator of the Ethics Administration) ii"- Filer Spouse Name of Governmental Entity: Nature of Contract/Sub-Contract: Value [of thing of economic value] Derived: Filer imiSpouse Name of Governmental Entity: Nature of Contract/Sub?Contract: Value (of thing of economic value) Derived: l? Filer F7 Spouse Name of Governmental Entity: Nature of Contract/Sub-Contract: Value (of thing of economic value) Derived: lw Filer Spouse Name of Governmental Entity: Nature of Contract/Sub-Contract: Value [of thing of economic value) Derived: You are required to complete SCHEDULE 0 if you are a member of the Ethics Adjudicatory Board; a member of the Board of Ethics; or if you serve as administrator of the Ethics Administration. You are required to disclose the name of each governmental entity from which you or your spouse derives a "thing of economic value? through a contract or subcontract involving a governmental entity, including the Louisiana Insurance Guaranty Association, the Louisiana Health Insurance Guaranty Association, Louisiana Citizens Property Insurance Corporation, the Property Insurance Association of Louisiana, and any other quasi-public entity. You are required to disclose the nature of the contract or subcontract, and the value of the "thing of economic value" derived. *?Thing of Economic Value? means money or any other thing having economic value. The complete definition of "thin?l'of economic value" can be found at La. R.S. 42:1102l22). Revised October 2014 Form 416A