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LOUISIANA BOARD OF ETHICS <br /> Mail: P.O. Box 4368, Baton Rouge, LA 70821 <br /> Fax: 225-389.-7271. <br /> Upload: https://eap.ethics.la.gov/FileUpload <br /> SPOUSAL PROHIBITED INCOME DISCLOSURE STATEMENT <br /> La. R.S. 42:11 1 1 C(5) <br /> � � <br /> PRINT FULL Name of public servant: <br /> Public office held by public servant: <br /> Public servant's agency: <br /> Start date of above position: <br /> Mailing Address: <br /> City,State,Zip: <br /> PRINT fUll Name of Spouse: <br /> Spouse's Employer: <br /> Spouse's Employer's Mailing Address: <br /> City,State Zip: <br /> Spouse's Date of Employment: <br /> Description of nature oF relationship beiween pubiic servant's agency and spouse's employer: <br /> Start Date of Relationship: <br /> By our signatures below,we do hereby certify that ali of the following are true and correct: <br /> 1. _ ___ (name of spouse) is a salaried orwage-earning employee of <br /> _ �name of spouse's employerj. <br /> 2. __ _ _'s (name of spouse) compensation is substantially unaffected by the <br /> contractual,business or financial relationship with (name of <br /> public servant's agency). <br /> 3. Neither . (name of public servant), nor _ __ <br /> (public servant's spouse) are an owner,officer director,trustee,or partner in <br /> _____ __ _ (name of spouse's employer�. <br /> 4. ____ _ _ (name of public servant)wili recuse/disqualify myself from <br /> participating in transactions involving_ _ _(name of spouse's employer). <br /> 5 ___ _ __(name of spouse)will file annual disclosure reports pursuant to La. R.S. <br /> 42:1 1 14 by May 15th. <br /> Certificate of Accuracv <br /> We do hereby certify that the information contained in this disclosure statement is true and correct to the best of our <br /> kriowledge and belief. <br /> Public Servc�nts Spouse <br /> Signature: Signature: <br /> Date: Date: <br /> Revised June 2023 Form 423 www.ethics.la.gov <br />