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E225-381-7271 BOARD OF ETHICS 368,Baton Rouge,LA 70821 //eap.ethics.1a.gov/FileUpload CONTRACT DISCLOSURE STATEMENT Pursuant to La.R.S.42:11131)(4) YEAR COVERED: FILER: ❑PUBLIC SERVANT Name: Position Held: Name of Department/Agency/Division: Address: City,State,Zip: ❑SPOUSE OF PUBLIC SERVANT Name: Address: City,State,Zip: Name of Public Servant: Position Held: Name of Department/Agency/Division: Address: City,State,Zip: ❑ IMMEDIATE FAMILY MEMBER OF PUBLIC SERVANT(RELATIONSHIP): Name: Address: City,State,Zip: Name of Public Servant: Position Held: Name of Department/Agency/Division: Address: City,State,Zip: I hereby certify and acknowledge that the information provided herein is true and correct to the best of my knowledge, information and belief, and that no information required by Section 11131)(4)(a) and/or (b) of the Code of Governmental Ethics has been deliberately omitted. Name of Filer Signature of Filer Date Revised December 2021 Form 411 www.ethics.1a.gov