Form 28B - Statement of Affairs by an Individual - Community Law

Denise Reed (Chair)Dept. of GeologyUniversity of New OrleansLakefrontNew Orleans, LA 70148Phone: 504-280-7395Fax: 504-280-7396E-mail: djreed@uno.eduCREST Technical Board Representatives9.12.07Len BahrGovernor’s Office for Coastal ActivitiesPO Box 94004Baton Rouge, LA 70804-9004Also: Energy, Coast and Environment BldgLSUBaton Rouge, LA 70803Phone: 225-342-3968 225-578-5174 (LSU)Fax: 225-342-5214E-mail: Len.bahr@gov.state.la.usPhil BassEPA Gulf of Mexico ProgramMail Code EPA/CMPOBldg 1100, Room 232Stennis Space Center, MS 39529Phone: 228-688-2356Fax:E-mail: bass.phil@epa.govJerry CainMississippi Department of Environmental QualityPO Box 20305Jackson, MS 39289-1305Phone: 601-961-5100Fax: 601-961-5794Email: jerry_cain@deq.state.ms.usSteve CarmichaelNational Resources Conservation Service3737 Government StreetAlexandria, LA 71302Phone: 318-473-7774Fax: 318-473-7771E-mail: steve.carmichael@la.usda.gov

Average weekly income frominvestments in banks, buildingsocieties, shares, etc.Other (e.g. Family Allowance – givedetails).TOTAL GROSS WEEKLY INCOME:2. WEEKLY EXPENSESIncome tax.Superannuation.Health insurance.Union fees.Housing (mortgage, board, rent).Clothing and shoes.Medical and chemist expenses.Entertainment.Payments on Court orders and fines.Other expenses (give details).TOTAL WEEKLY EXPENSES:3. Are there any persons who contribute topaying your expenses? If so, who arethey and how much do they contribute?4.PROPERTY AND ASSETSMarket value of house (place of residence)owned.Amount owing on mortgage.

Net value of interest on house.Market value of any other house or land.Amount owing on mortgage.Net value or interest in other house orland owned.Market value of motor vehicle(s).(a) YearMake/model.(b) YearMake/model.Amounts owing under finance on motorvehicles.Net value of interest(s) on motor vehicles.Cash in banks, building societies, etc.Cash on hand.Value of other investments includingshares, debentures, bonds.Money owed to you.Value of interest in partnership orbusiness (including stock, goodwillequipment, debtors).State approximate re-sale value offurniture and personal goods.Net value of interest.Other assets (give details)TOTAL NET VALUE:Life insurance policies (specify insurer,policy number, surrender value(s)).TOTAL PROPERTY AND ASSETS:Are any assets jointly owned?details.Give

5. Debts and Liabilities (give details)Municipal rates.Water and sewerage rates.Land tax.Child care costs (kindergarten, day care,etc.).Maintenance actually paid.Instalment payments (state purpose).Electricity.Gas.Telephone.Food.Other general household expenses.Car expenses (registration, insurance,maintenance, fuel).Fares.Insurance policies.School fees and other schooling costs.Hire purchase, leases, credit cards, creditcontracts, personal loans, store accounts,guarantees being paid off, etc.)Total amount due.To:Total amount due.To:Total amount due.To:TOTAL OTHER DEBTS:6. Have any of the above debts been jointlyincurred with any other person? Givedetails.7. Give details of any other circumstanceswhich affect your financial position (e.g.number and age of dependents, maritalstatus, health, etc.).Date: _____/_____/_____________________________________SignatureWARNINGAN INSTALMENT ORDER THAT IS MADE AS A RESULT OF A FALSESTATEMENT MAY BE VARIED OR CANCELLED