TOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 7082L !a tt 1' '.; TIER 2 PERSONAL FINANCIAL DISCLOSURE STATEMENT (ANNUAL) MORIGINAL REPORT This Report Covers Calendar Year: 2OLT NAMENDED REPORT I I currently hold an office that would require me to file a Tier 2.1, or Tier 3 Personal Financial Disclosure Statemenl As such, I have completed SCHEDULE L. Office/Position Held: Clerk of Civil District Court Dale l{. Atkins Mailing Address 2411 Oriole Street City, State, Zip New Orleans Name of Filer [print full name) Name of SpouSe (printfullnameJ Spouse's Occupation LA 7OL22 il/A N/A Spouse's Principal Business Address City, State, Zip Check all that apply: ffil have filed my state income tax return for the previous year. Il have filed for an extension of my state income tax return for the previous year. ffil have filed my federal income tax return for the previous year. Il have filed for an extension of 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 AND I am requesting an extension in filing my Tier 2 Personal Financial Disclosure, Certification of Accuracy I do hereby certify, after having been duly sworn, that the information contained in this personal financial disclosure statement is true and correct to the best of my knowledge, information, and belief. Signature of Filer sworn to and subscribed before me this !!3^, tf fr"U .,20/J clrl,., Notary Public (signatureJ ,ro -33( /5' Date Commission Expires Revised February 2012 Form 4764 -1{ w w w. ethi c s. state. I a. u s LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821, Schedule A: rmployment Information n Check if not applicable ffifiler [spouse ffiFull-Time IPart-Time fobTitle: Clerk - Civil District Court Nameof Employer: Clerk of Civil District Court Address: 421 Loyola Avenue. Roorn 402 City, State, Zip: New Qrleans- LA 71tt2 fob Description: [Filer Clerk of Court flSpouse IFull-Time IPart-Time fob Title: Name of Employer: Address: City, State, Zip: Iob Description: [Filer [spouse IFull-Time IPart-Time Iob Title: Name of Employer: Address: City, State, Zip: fob Description: ilFiler [Spouse IFull-Time IPart-Time fob Title: Name of Employer: Address: City, State, Zip: fob Description: r You are required to disclose employment information related to both you and your spouse. . 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 pan-time. Revised February 2012 Form 4164 www.ethics.state.la.us LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule B: Positions - Business ffi Check flFiler if not applicable [spouse [Both Amount of Interest (amount exceeds 100/o)l }IOT APPLICABLE % Name of Business: Address: City, State, Zip: Business Description: Nature of Association: [Filer [spouse f,Both Amount of Interest (amount exceeds 10%l: % Name of Business: Address: City, State, Zip: Business Description: Nature of Association: fiFiler [Spouse [Both Amount of Interest (amount exceeds 100/o): % Name of Business: Address: City, State, Zip: Business Description: Nature of Association: + You are required to complete SCHEDUTE B if you or your spouse is a director, officer, owner, paftner, member, or trustee of a business AND if you or your spouse leither individually or collectively) owns an interest in a business which exceeds 10%. * "Business" means any corporation, partnership, sole proprietorship, firm, enterprise, franchise, association, business, organization, selfemployed individual, holding company, trust, or any other legal entity or person, Revised February 2012 Form 4764 www. eth i c s. state. I a.u s LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 7082L Schedule C: Positions - Nonprofit ffi Check IFiler if not applicable Ispouse NOT APPLICABLE Name of Organization: Address: City, State, Zip: Nature of Association: Description of Organization: flFiler Ispouse Name of Organization: Address: City, State, Zip: Nature of Association: Description of Organization: IFiler ISpouse Name of Organization: Address: City, State, Zip: Nature of Association: Description of 0rganization : *You are required to complete SCHEDULE Revised February 2012 C if you or your spouse is a director or officer of a nonprofit agency. Form 4164 www.ethics.state.la.us TOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821, SChgdUle D: n Income from the State, Political check if not applicable Subdivisions,and/or Gaming lnterests KFiler [Spouse nBusiness fwhere amount of interest exceeds 10%] Type of Income: nstate nPolitical Subdivision IGaming Interest Name of Business (if applicable): NameoflncomeSource: Clerk of Civil District Address: 421 Lovola Avenue- City,State,Zip: New Amount of Income IFiler 0rleans. LA fexact doltar amounr): Ispouse Court- for 0rleans Parish Room 4O2 7OLL2 $tSg.gg0.OO EBusiness (where amount of interest exceeds 10%J Type of Income: nstate IPolitical Subdivision IGaming Interest Name of Business (if applicable): Name of Income Source: Address: City, State, Zip: Amount of Income f]Filer [exact dollar amount): $ nspouse flBusiness(whereamountofinterestexceedsl0%J Type of Income: ilState IPolitical Subdivision nGaming Interest Name of Business fif applicable): Name of Income Source: Address: City, State, Zip: Amount of Income (exact dollar amount): $ * You are required to complete SCHEDULE D if you or your spouse received income from the State, any political subdivision, andlor 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. * "lncome" (for a business) means gross income less costs of goods sold, and operating expenses. * "lncome" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. * The definitions for (and examples oll political subdivision, gaming interest, and business are found in the ,nstructio ns Section of this form. Revised February 2012 Form 4164 www,ethics'state'la'us LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821, Schedule E: Income D0 Check flFiler if not applicable Received from Employment fFull-Time [Part-Time NOT APPLICABLE f]Spouse Name of Source of Income: Address: City, State, Zip: Nature of Services Rendered fpursuant to such employmentJ: Amount of Income: Iriler I fl $5,000] n III ($2s,000-$100,000J I Category I fiess than Category II ($s,000-$24,999J Category Category IV (more than $100,000) fispouse IFull-Time f]Part-Time Name of Source of Income: Address: City, State, Zip: Nature of Services Rendered fpursuant to such employmentJ: Amount of Income: Iriler I I $5,000) [ III [$2s,000-$100,000J I Category I Category [Spouse (less rhan Category II ($5,000-$24,999J Category IV (more than $100,000] ffFull-Time IPart-Time Name of Source of Income: Address: City, State, Zip: Nature of Services Rendered (pursuant to such employment): mount of Income: I I $5,000) [ III ($2s,000-$100,000J fl Category I Category fless ttran Category II ($5,000-$24,999J Category IV fmore than $100,000) * You are required to complete SCHEDULE E to disclose the income received by you or your spouse for each full-time or part-time employment position held. *lncome that is reported on SCHEDULE D does not have to be restated on SCHEDULE E. *f ncome received through self-employment is reported on SCHEDULE F. * "lncome" (for a business) means gross income less costs of goods sold, and operating expenses. * "lncome" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. Revised February 2012 Form 4164 www. ethi c s. sta te. I a.u s LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821. Schedule F: Income E Check if not Received from BUSineSS IntefeStS applicable AGGREGATE AMOUNT OF INCOME RECEIVED FROM BUSINESS INTERESTS: f, I $s,000) fl Category III ($2s,000-$100,000) [ Category I [riter 0ess than [Spouse Category II ($s,000-$24,eee) Category IV (morethan $100,000] NoT APPLICABLE Name of Business: Address: City, State, Zip: Nature of services rendered oR reason income was received: Ifiler ISpouse Name of Business: Address: City, State, Zip: Nature of services rendered oR reason income was received: IRiler Ispouse Name of Business: Address: City, State, Zip: Nature of services rendered oR reason income was received: tYou are required to complete SCHEDULE F if you or your spouse received income from a business interest, * "lncome" (for a businessf means gross income less costs of goods sold, and operating expenses, * "lncome" (for an individuall means taxable income and shall not include any income received pursuant to a life insurance policy. *lncome reported on SCHEDULE D or E does not have to be restated on SCHEDULE F. Revised February 2012 Form 4164 www'ethics.state.la.us LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821, Schedule G: other Income [ ] Check Iriter if not applicable {any other income that exceeds $t,000 from each source) Ispouse Description of Income: FIRST NBC BANK Nature ofservices rendered or reason income was received: Bank Board Amount of Income: Filer I I $5,000) fi III 1$zs,ooo-$roo,oool I Category I Category Director fless t]ran C"t.gory II ($s,000-$24,9991 Category IV lmore rhan $100,000J Ispouse Description of Income: Nature of services rendered or reason income was received: mount of Income: Iriter I I $5,000J I III ($2s,000-$100,000) [ Category I Category (less rhan Category II t$s,000-$24,e99J Category IV (more than $100,000J ISpouse Description of Income: Nature ofservices rendered or reason income was received: Amount of Income: I fl $s,000) [ III ($2s,000-$100,0001 [ Category I Category (less than Category Il 1$s,ooo-$z+,ooo1 Category IV fmore than $100,000) xYou are required to complete SCHEDULE G if you or your spouse received any other type of income that exceeded 51,000 from any one source. * "lncome" (for a business) means gross income less costs of goods sold, and operating expenses. * "lncome" (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*lncome that is reported on SCHEDULE D, E, or F does not have to be restated on SCHEDULE G, Revised February 2012 Form 416A www. eth i c s,sta te. I a. u s LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70827 Schedule H: lmmovable Property il Check if not (a property that exceeds $2,000 in value) applicable ffFiler [Spouse [Both Location of Property Country: State: LouiSiana USA Parish/County: 0rleans Description of Property: Residence or Value: Fair Market Use I Category I (less than $s,000] [ Category II [$s,000-$z4,eee) flCategory III ($2s,000-$100,0001 ffi Category IV fmore than $100,000J fiFiler [Spouse flBoth Location of Property Country: State: LOuiSiana USA Parish/County: 0rleanS Description of Property: prior to Hurrican Katrina Fair Market or I Category I (less than $5,000J fi Use Value: I Category III ($2s,000-$100,000) [ Residence C"t"gory II [$s,000-$24,eee) Category IV (more than $100,000] flFiler flSpouse fiBoth Location of Property Countrv: Parish/County: State: Description of Property' Fair Market or use value: I f, $5,000] f] III ($2s,000-$100,000J I Category I category (less ttran Category II t$s,000-$24,eee) Category IV lmore than $100,000J * You are required to disclose the location by country, 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 Februqry 2012 Form 4164 www.ethics.state.la.us LOUISIANA BOARD OF ETHICS Post Office Box 4358 Baton Rouge, Louisiana 70821, Schedule ll Investment Holdings ffi Check if not applicable [Filer [Spouse ffBoth (an investment holding that exceeds 55,000) NOT APPLICABLE Name of Security: Description of Security: [Filer [Spouse [Both Name of Security: Description of Security: fiFiler [Spouse flBoth Name of Securitv: Description of Security: * You are required to complete SCHEDULE I if you or your spouse holds investment securities where each investment security has a value that exceeds 55,000. * 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 Februarv 2012 Form 4764 www. ethi c s. state, I a.u s LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 7082I Sched ule J i Transactions ffi (a transaction Check if not applicable EFiter fispouse [Both that exceeds 55,000) iloT AppLIcABLE Transaction Date: Description of Transaction: Amount of Transaction: fl I $5,000) [ III ($25,000-$100,000] [ Category II ($5,000-$24,999] Category I 0essthan Category II ($5,000-$24,999] Category $5,000) [ III ($2s,000-$100,000) f] Category IV (morethan $100,000) Category I Category 0ess than Category IV (more than $100,000) [Filer [Spouse ilBoth Transaction Date: Description of Transaction: Amount ofTransaction: I I nFiler nspouse lBoth Transaction Date: Description of Transaction: ofTransaction: ! Category I 0essrhan $5,000J I Amount Category III ($25,000-$100,000] I [ Category II ($5,000-$24,999J Category IV (more than $100,000) I You are required to complete SCHEDULE J 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 immovable property or of any personally owned tax credit certificates, stocks, bonds, or commodities futures (which exceeds S5,000 each). * 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 February 2012 Form 416A w w w. ethi c s. state. I a. u s LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 7082L Schedule K: Liabitities ffi Check Ifiter if not applicable Ispouse (a liability that exceeds S10,000) NOT APPLICABLE Name of Creditor: Address: City, State, Zip: Name of Guarantor (lf applicable): IFiler ISpouse Name of Creditor: Address: City, State, Zip: Name of Guarantor (lf applicable): IFiler Ispouse Name of Creditor: Address: City, State, Zip: Name of Guarantor IFiler If applicable): Ispouse Name of Creditor: Address: City, State, Zip: Name of Guarantor If applicableJ: *You are required to complete SCHEDULE K if you or your spouse owes any liability which exceeds S10,000 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. 9:3516(13). *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" 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, R.S. 9:3516(13). Revised February 2012 Form 4764 www.ethics.state.la.us LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70827 Schedule L: other offices/Positions ffi Check Held if not applicable Name of Office/Position: NOT APpLICABLE Name of Office/Position: Name of Office/Position: Name of Offi ce/Position: Name of Office/Position: Name of Office/Position: Name of Offi ce/Position: Name of Office/Position: Name of Office/Position: Name of Office/Position: *You are required to complete SCHEDULE L if you hold any other office or position which would require you to file a personal financial disclosure statement under La. R.S, 42:1124.2,l or 42:L124.3. Revised February 2012 w w w. et h i c s. state. I a.us LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70827 Schedule M: Positions - Business X Check if not applicable (to be completed by members of the Ethics Adjudicatory Board and Ethics Board, and the administrator of the Ethics Administration) IFiler f]Spouse IBoth NOT APPLICABLE Name of Business: Address: City, State, Zip: Business Description: Nature of Association: Amount of Interest: IFiler ISpouse Yo IBoth Name of Business: Address: City, State, Zip: Business Description: Nature of Association: o Amount of Interest: f,Filer ISpouse IBoth Name of Business: Address: City, State, Zip: Business Description: Nature of Association: Amount of Interest: % * You are required to complete SCHEDULE M if you are a member of the Ethics Adiudicatory 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, selfemployed individual, holding company, trust, or any other legal entity or person, * lnformation disclosed on SCHEDULE B does not have to be restated on SCHEDULE M, Revised February 2012 Form 4164 www.ethics.state.la.us LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule N: Income from the State E ctrect irnot applicabre and/or Political Subdivisions (to be completed by members of the Ethics Adjudicatory Board and Ethics Board, and the administrator of the Ethics Administration) IFiler ISpouse IBusiness e of Income: IState XPolitical ]IOT APPLICABLE Subdivision Name of Business (if applicableJ: Name of Income Source: Address: City, State, Zip: Amount of Income (exact dollar amount): $ nFiler !Spouse oflncome: ilBusiness IState IPolitical Subdivision Name of Business (if applicable): Name of Income Source: Address: City, State, Zip: Amount of Income [exact dollar amount): $ nFiler ISpouse of Income: ilBusiness ilState IPolitical 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 N if you are a member of the Ethica 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, * "lncome" (for a business) means gross income less costs of goods sold, and operating expenses. * "lncome" (for an individual) means taxable income and shall not include any income received pursuant to a life insurance policy. * lnformation disclosed on SCHEDULE D does not have to be restated on SCHEDULE N. Revised February 2012 Form 4164 www.ethics.state.la.us LOUISIANA BOARD OF ETHICS Post Office Box 4368 Baton Rouge, Louisiana 70821 Schedule O: lncome from I checkifnorapplicable (to a GOvernmental Entity be completed by members of the Ethics Adjudicatory Board and Ethics Board, and the administrator of the Ethics Administration) IRiler Ispouse NOT APPLICABLE Name of Governmental Entitv: Nature of Contract/Sub-Contract: Value (of thing of economic valueJ Derived: IFiler Ispouse Name of Governmental Entity: Nature of Contract/Sub-Contract: Value fof thing of economic value) Derived: IFiler [spouse Name of Governmental EntiW: Nature of Contract/Sub-Contract: Value (of thing of economic value) Derived: Iriter Ispouse Name of Governmental EntiW: Nature of Contract/Sub-Contract: Value (of thing of economic value) Derived: * You are required to complete SCHEDULE O 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 'thing of economic value" can be found at La. R.5. 42ttl02l22l. Revised February 2012 Form 416A www.ethics.state.la'us