Revised August 2018 Form 413 www.ethics.la.gov
LOUISIANA BOARD OF ETHICS
Post Office Box 4368
Baton Rouge, Louisiana 70821
Fax 225-381-7271
https://eap.ethics.la.gov/FileUpload
COMPLIMENTARY ADMISSION, LODGING AND/OR TRANSPORTATION
DISCLOSURE STATEMENT
Pursuant to La. R.S. 42:1115.2, any public servant who accepts complimentary admission, lodging, or transportation, or
reimbursement for such expenses shall file a certification with the Board of Ethics
WITHIN 60 DAYS AFTER SUCH ACCEPTANCE.
Agency Head Certification (to be completed prior to attendance):
By my signature below, I, ____________________________________________, (print name)
• Certify that the Public Servant’s acceptance of the complimentary admission, lodging and transportation, or
reimbursement of such expense (check applicable box), ☐is of direct benefit to the agency or ☐ will enhance
the knowledge or skill of the Public Servant as it relates to the performance of his public service.
• Approve the Public Servant’s acceptance of the complimentary admission, lodging and transportation, or
reimbursement of such expense.
AGENCY HEAD’S SIGNATURE: ______________________________________________
DATE: ______________________________________________
Public Servant Attestation:
By my signature below, the above provided information is true and correct to the best of my knowledge, information,
and belief.
PUBLIC SERVANT’S SIGNATURE: _______________________________________
DATE: ______________________________________________
PUBLIC SERVANT’S FULL NAME
: _______________________________________________________________________________________
ADDRESS: _____________________________________________________________________________________________________________________
CITY, STATE, ZIP: ____________________________________________________________________________________________________________________
POSITION TITLE: _________________________________________________________________________________________________________
EMPLOYING AGENCY: _____________________________________________________________________________________________________________
DATE OF EVENT: ___________________________________________________________________________________
LOCATION: ___________________________________________________________________________________________________________________
DESCRIPTION OF PURPOSE OF PUBLIC SERVANT’S ACCEPTANCE OF COMPLIMENTARY ADMISSION, LODGING AND/OR
REASONABLE T
RANSPORTATION: __________
________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
_______________________________________________________________
____________________________________________________________________________
PERSON/ORGANIZATION PROVIDING
ADMISSION, LODGING, AND/OR TRANSPORTATION
: ___________________________________________________________
AMOUNT EXPENDED/REIMBURSED ON PUBLIC SERVANT
ADMISSION: $___________________ LODGING: $__________________ TRANSPORTATION: $___________________
Southeastern
TA# __________
