Free LOUISIANA SUPREME COURT - Louisiana

LOUISIANA SUPREME COURT PERSONAL FINANCIAL DISCLOSURE FORM FOR JUDGES
SECTION I: GENERAL INFORMATION
2. Date of Report

Report Required by Order of the Louisiana Supreme Court, Part N, Rule XXXIX.

1. Person Reporting (Last name, first, middle initial)

3. Reporting Period

4. Title of Person Reporting

5. Name of Court

6. Office Address

7. Spouse's Name (Last name, first, middle initial)

8. Spouse's Occupation (if applicable)

NOT APPLICABLE
9. Spouse's Office Address (if applicable)

NOT APPLICABLE NOT APPLICABLE

IMPORTANT: The instructions accompanying this form must be followed. Complete all parts, checking the "NOT APPLICABLE" box for each part where you have no reportable information.

SECTION II:

EMPLOYMENT

Please provide the name of the employer, job title, and a brief job description of each full-time or part-time position held by you and your spouse for the preceding calendar year. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section 2(C)(3). 1. Information Relates to: Filer Spouse 2. Position: 3. Name of Employer 4. Job Title 5. Brief Description of Employment 1. Information Relates to: 2. Position: 3. Name of Employer 4. Job Title 5. Brief Description of Employment Filer Full-Time Spouse Part-Time Full-Time Part-Time

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

SECTION III.

INTERESTS IN BUSINESS ENTITIES

If you and/or your spouse are a director, officer, owner, partner, member or trustee in any business and own in excess of ten percent of such business, either individually or collectively, complete Section III. Otherwise, check the "NOT APPLICABLE" box and skip to the next Section. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section 2(C)(4)(a). NOT APPLICABLE 1. Information Relates to: 2. Name of Business Filer Spouse 3. Address of Business: Both

4. Brief Description of, and Amount of Interest in, Business 5. Nature of Association with Business 1. Information Relates to: 2. Name of Business

Director Partner Filer

Officer Member Spouse

Owner Trustee Both

3. Address of Business:

4. Brief Description of, and Amount of Interest in, Business 5. Nature of Association with Business

Director Partner

Officer Member

Owner Trustee

SECTION IV.

INVOLVEMENT IN NONPROFIT ORGANIZATIONS

If you and/or your spouse are a director or officer of a nonprofit organization, complete Section IV. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section 2(C)(4)(b). Otherwise, check the "NOT APPLICABLE" box and skip to the next Section. 1. Information Relates to: Filer Spouse 2. Name of Nonprofit 3. Address of Nonprofit: NOT APPLICABLE Both

4. Brief Description of Nonprofit

5. Nature of Association with Nonprofit 1. Information Relates to: 2. Name of Nonprofit

Director

Officer Both

Filer Spouse 3. Address of Nonprofit:

4. Brief Description of Nonprofit

5. Nature of Association with Nonprofit

Director

Officer

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

SECTION V.

INCOME

This Section solely concerns income earned by you and/or your spouse in the preceding calendar year. Please note that each subsection requests information concerning specific sources of income. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section 2(C)(5).

Subsection A.

Income from State or Political Subdivision or from Services Performed for or in Connection with a Gaming Interest

Complete this Subsection only if either you or your spouse, or if any business in which you or your spouse, either individually or collectively, own more than a ten percent interest, receives any source of income from services performed for or in connection with a gaming interest, or from the state or any political subdivision. (See Definitions for the definition of gaming interest or political subdivision.) Otherwise, check the "NOT APPLICABLE" box and skip to the next Subsection. NOT APPLICABLE 1. Information Relates to: Filer Spouse Business in which Filer and/or Spouse owns 10% interest 2. Name of Source of Income 3. Address of Source of Income:

4. Type of Income Received:

State or Political Subdivision Services Performed for or in Connection with a Gaming Interest

5. Specific Amount of Income Received: 1. Information Relates to: 2. Name of Source of Income Filer Spouse Business in which Filer and/or Spouse owns 10% interest 3. Address of Source of Income:

4. Type of Income Received:

State or Political Subdivision Services Performed for or in Connection with a Gaming Interest

5. Specific Amount of Income Received: 1. Information Relates to: 2. Name of Source of Income Filer Spouse Business in which Filer and/or Spouse owns 10% interest 3. Address of Source of Income:

4. Type of Income Received:

State or Political Subdivision Services Performed for or in Connection with a Gaming Interest

5. Specific Amount of Income Received:

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

Subsection B.

Income from Employers

Provide the name and address of any employer who provided income to you or your spouse pursuant to fulltime or part-time employment. In your response, include a brief description of the nature of the services rendered pursuant to such employment and the amount of such income. You do not need to include information that was reported pursuant to the previous Subsection. If none, check the "NOT APPLICABLE" box and skip to the next Subsection. 1. Information Relates to: 2. Position Filer Full-Time Spouse Part-Time 3. Name of Employer 4. Address of Employer: NOT APPLICABLE

5. Job Title 6. Brief Description of the Nature of Services Rendered 7. Amount of Income Received LESS THAN $5,000 $25,000 - $100,000 2. Position Full-Time Part-Time 4. Address of Employer: $5,000 - $24,999 MORE THAN $100,000

1. Information Relates to: Filer Spouse 3. Name of Employer

5. Job Title 6. Brief Description of the Nature of Services Rendered 7. Amount of Income Received LESS THAN $5,000 $25,000 - $100,000 2. Position Full-Time Part-Time 4. Address of Employer: $5,000 - $24,999 MORE THAN $100,000

1. Information Relates to: Filer Spouse 3. Name of Employer

5. Job Title 6. Brief Description of the Nature of Services Rendered 7. Amount of Income Received LESS THAN $5,000 $25,000 - $100,000 $5,000 - $24,999 MORE THAN $100,000

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

Subsection C.

Income from Businesses

Provide the name and address of all businesses that provide income to either you or your spouse. In your response, include a brief description of the services rendered for each business or the reason that such income was received. You do not need to include information that was reported pursuant to the previous two Subsections. If none, check the "NOT APPLICABLE" box and skip to the next Subsection. 1. Information Relates to: Filer Spouse 2. Name of Business 3. Address of Business NOT APPLICABLE

4. Brief Description of the Nature of Services Rendered, or, if none, the Reason Such Income was Received 5. Amount of Income Received 1. Information Relates to: 2. Name of Business

LESS THAN $5,000 $25,000 - $100,000 Filer Spouse 3. Address of Business

$5,000 - $24,999 MORE THAN $100,000

4. Brief Description of the Nature of Services Rendered, or, if none, the Reason Such Income was Received 5. Amount of Income Received

LESS THAN $5,000 $25,000 - $100,000

$5,000 - $24,999 MORE THAN $100,000

Subsection D.

Miscellaneous Income

If you or your spouse have received any other income that exceeds $1,000, complete this Subsection. You do not need to include information that was reported pursuant to the previous three Subsections. If none, check the "NOT APPLICABLE" box and skip to the next Section. 1. Information Relates to: Filer Spouse 2. Type of Other Income 3. Brief Description of the Nature of Services Rendered, or, if none, the Reason Such Income was Received 4. Amount of Income Received 1. Information Relates to: 2. Type of Other Income 3. Brief Description of the Nature of Services Rendered, or, if none, the Reason Such Income was Received 4. Amount of Income Received NOT APPLICABLE

LESS THAN $5,000 $25,000 - $100,000 Filer Spouse

$5,000 - $24,999 MORE THAN $100,000

LESS THAN $5,000 $25,000 - $100,000

$5,000 - $24,999 MORE THAN $100,000

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

SECTION VI.

INTERESTS IN IMMOVABLE PROPERTY

If you or your spouse, either individually or collectively, have an interest in any parcel of immovable property that exceeds $2,000 in fair market value or use value, as determined by an assessor for purposes of ad valorem taxes, complete this Section. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section (C)(6). If none, check the "NOT APPLICABLE" box and skip to the next Section. 1. Information Relates to: Filer Spouse 2. Location of Immovable Property Parish/County NOT APPLICABLE Both

State

3. Brief Description of Immovable Property 4. Fair Market Value or Use Value: 1. Information Relates to: LESS THAN $5,000 $25,000 - $100,000 Filer Spouse $5,000 - $24,999 MORE THAN $100,000 Both

2. Location of Immovable Property Parish/County

State

3. Brief Description of Immovable Property 4. Fair Market Value or Use Value: 1. Information Relates to: LESS THAN $5,000 $25,000 - $100,000 Filer Spouse $5,000 - $24,999 MORE THAN $100,000 Both

2. Location of Immovable Property Parish/County 3. Brief Description of Immovable Property 4. Fair Market Value or Use Value: 1. Information Relates to: LESS THAN $5,000 $25,000 - $100,000 Filer

State

$5,000 - $24,999 MORE THAN $100,000 Both

Spouse

2. Location of Immovable Property Parish/County 3. Brief Description of Immovable Property 4. Fair Market Value or Use Value: LESS THAN $5,000 $25,000 - $100,000

State

$5,000 - $24,999 MORE THAN $100,000

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

SECTION VII.

INVESTMENT SECURITIES

If you or your spouse hold(s) any investment securities having a value exceeding $5,000, complete this Section. You do not need to disclose any 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. See the Instructions Section for items that should not be reported in this Section. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section 2(C)(7). If neither you nor your spouse holds such investment securities, check the "NOT APPLICABLE" box and skip to the next Section. NOT APPLICABLE 1. Information Relates to: 2. Name of Investment Security 3. Brief Description of Investment Security 1. Information Relates to: 2. Name of Investment Security 3. Brief Description of Investment Security 1. Information Relates to: 2. Name of Investment Security 3. Brief Description of Investment Security 1. Information Relates to: 2. Name of Investment Security 3. Brief Description of Investment Security 1. Information Relates to: 2. Name of Investment Security 3. Brief Description of Investment Security 1. Information Relates to: 2. Name of Investment Security 3. Brief Description of Investment Security Filer Spouse Both Filer Spouse Both Filer Spouse Both Filer Spouse Both Filer Spouse Both Filer Spouse Both

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

SECTION VIII.

PURCHASE/SALE

If you or your spouse have purchased or sold, in excess of $5,000, any immovable property or any personally owned tax credit certificates, stocks, bonds, or commodities futures, including any option to acquire or dispose of any immovable property or of any personally owned tax credit certificates, stocks, bonds, or future commodities, complete this Section. See the Instructions Section for items that do not need to be reported in this Section. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section 2(C)(8). If your answer is none, check the "NOT APPLICABLE" box and skip to the next Section. NOT APPLICABLE 1. Information Relates to: 2. Type: Purchase 4. Amount of Purchase or Sale: 5. Brief Description of What Was Purchased or Sold: 1. Information Relates to: 2. Type: Purchase 4. Amount of Purchase or Sale: 5. Brief Description of What Was Purchased or Sold: 1. Information Relates to: 2. Type: Purchase 4. Amount of Purchase or Sale: 5. Brief Description of What Was Purchased or Sold: 1. Information Relates to: 2. Type: Purchase 4. Amount of Purchase or Sale: 5. Brief Description of What Was Purchased or Sold: Sale $5,000 - $24,999 MORE THAN $100,000 $25,000 - $100,000 Filer Spouse Both Sale $5,000 - $24,999 MORE THAN $100,000 $25,000 - $100,000 Filer Spouse Both Sale $5,000 - $24,999 MORE THAN $100,000 $25,000 - $100,000 Filer Spouse Both Sale $5,000 - $24,999 MORE THAN $100,000 $25,000 - $100,000 Filer Spouse Both 3. Date of Purchase or Sale:

3. Date of Purchase or Sale:

3. Date of Purchase or Sale:

3. Date of Purchase or Sale:

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

SECTION IX.

CREDITORS

Complete this Section if you or your spouse owes any liability to any creditor which exceeds $10,000 on the last day of the reporting period. See the Instructions Section for liabilities that are excluded from this Section. See Rules of the La. Supreme Ct., Part N, Rule XXXIX, Section 2(C)(9). If you owe no liability exceeding $10,000, check the "NOT APPLICABLE" box and skip to the next Section. NOT APPLICABLE 1. Information Relates to: 2. Creditor's Name Filer Spouse Both 3. Creditor's Address

4. Guarantor's Name (if applicable) NOT APPLICABLE 1. Information Relates to: 2. Creditor's Name Filer Spouse Both

3. Creditor's Address

4. Guarantor's Name (if applicable) NOT APPLICABLE 1. Information Relates to: 2. Creditor's Name Filer Spouse

3. Creditor's Address

4. Guarantor's Name (if applicable) NOT APPLICABLE 1. Information Relates to: 2. Creditor's Name Filer Spouse Both

3. Creditor's Address

4. Guarantor's Name (if applicable) NOT APPLICABLE 1. Information Relates to: 2. Creditor's Name Filer Spouse Both

3. Creditor's Address

4. Guarantor's Name (if applicable) NOT APPLICABLE

COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY

PERSONAL FINANCIAL DISCLOSURE AFFIDAVIT
The law requires the personal financial disclosure statement to be verified. The verification page must have the signature of the individual required to file the personal financial statement, as well as the signature and stamp or seal of office of a notary public or other person authorized by law to administer oaths and affirmations. Without proper verification, the statement is not considered filed.

STATE OF LOUISIANA PARISH OF BEFORE ME, the undersigned authority, personally came and appeared:

who, upon first being duly sworn, did depose and say that the information contained in this Personal Financial Disclosure form is true and correct to the best of his/her knowledge, information, and belief. He/She has either filed his/her federal and state income tax returns or has filed an extension of time for filing such tax returns.

____________________________________

Sworn to and subscribed before me this day of , 20

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Notary Public