i^^o^ ST. Tflmm^yM of Ward/District BvJ5H Parish Constable 5 (City) Louisiana Financial Statements As of and for the Year December 31, Z C \ Z Required by Louisiana Revised Statutes 24:513 and 24:514 to be filed with the Legislative Auditor Within 90 days after the close ofthe fiscal year. AFFIDAVIT Personally came and appeared before the undersigned authority, Constable (your name) i>i<PbJgaor^CgftuOrae(^. who, duly sworn, deposes and says that the financial statements herewith given present fairiy the financial position of the Court of ST. IThn^lMlJ^ Parish. Louisiana, as of December 31, ^ l 3 . and the results of operations for the year then ended, on the cash basis of accounting. In addition, (your name) L A / £ ^ i i l > i J ' M ^ R p t : > that the Constable of Ward/District S ^ who duly swom, deposes, and says and STilfMiniiiH Parish received $200,000 or less in revenues and other sources for the year ended December 31. Z ^ Z . and accordingly, is required to provide a swom financial statement and affidavit and is not required to provide for an audit, review/attestation, or compilation report for the previously mentioned fiscal year. Signature of Cons Swom to and subscribed before me, this &z. day of lA'^Cti NOTARY PUBLIC Signature Please Complete this Section: Under provisions of state law, this report is a public Constable's Name L>UCU^<30D C ^ M f Q S ^ document. Acopy of the report has been submitted to Street/P.O.Box Address 7 ? Z / g t^J^TJ^'-VtofV^ ^ P i ~ the entity and other appropriate public officials^ 1 he QHy/^jp Code ^i)?,U L J 4 '7/>0s/ report is available for public inspection at the Baton j J J ; isjumber ^ 9 ^ ^ 9^lJ'9Q^^ Rouge office ofthe Legislative Auditor and. v^here ' ®'®P"°"^ tMumoer ^ y ^ yr6 . ^ y ^ r appropriate, at the office of the parish clerk of court. Fax Number —, MAR 2 6 201'^ ^"^^'' ^^^''®®^ liiObdAfc. i - w i s ^ c ^ j ^ L A i l , com. Release Date Please retum the completed form bv March 31 to Office of Leaislative Auditor - Local Government Services. Post Office Box 94397. Baton Rouae. LA 70804-9397 Statement A Page 3 .(Constable Name) Q T . n t M l t f a J ^ Parish Constable of Ward / District _ 5 (City) Louisiana Statement of Cash Receipts and Disbursements For the Year Ended December 31, 2^0)3 General Fund CASH RECEIPTS: 1. State & Parish salary (reauired. fmm W-2 Fonn) Fees collected (As constable, if any were collected) Gamishments collected (if applicable) Other ^ ^ ^ _ _ Total cash receipts. Add lines 1 through 4 CASH DISBURSEitflENTS: 6. Cost of equipment purchased (fax machine, etc.) 7. Materials and supplies (stationery, postage, etc.) 8. Travel and other charges 8a. Foryourself 8b. For employees (If applicable) 9. Other operating expenses (rent, utilities, phone/fax line, etc.) 10. Gamishments paid to others [From total collections on Une 3] 11. Total disbursements (add lines 6-10) 1. 2. 4. 5. 6. 7. 8a 8b 9 Gamishment Fund Activity IT^OO iOOO o 3. 9ze>o .^^iD foO ilUO 10. 11. 12. Balance Available (loss) for payment of salaries (General Fund: Line 5 less Line 11; Gamishment Fund 12. Activity: Line 3 less Line 10) /OOP 7Zd>CP 12. a 13. 14. o o 15. O Salary and related benefits: 13. Amount retained by yourself from line 12 as salary 14. Amount paid to employees (if applicable) 13. 14. 15. Total salaries paid (add lines 13 and 14) 15. 7Z£X? O 7Z4S^ 16. O 16. £> 17. ^ 17. a 18. a 18. o FUND BALANCE 16. Increase (decrease) in fund balance, may be $0 (line 12 less line 15) 17. Fund Balance at beginning of the year, may be $0 (Ending Fund balance from last year's report) 18. Fund balance (deficit) at end of the year, may be $0 (Add lines 16 and 17) Please retum the comoleted fomi bv March 31 to Office of Leaislative Auditor - Local Govemment Services. Post Office Box 94397. Baton Rouae. LA 70804-9397