Affidavit and Revenue Certification. Martin Luther King Health Center Caddo Parish Shreveport, Louisiana

Transcription

1 /oolo Affidavit and Revenue Certification Caddo Parish Shreveport, Louisiana ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $50,000 OR LESS (if applicable) The annual sworn financial statements are required by Louisiana Revised Statute 24:514 to be filed with the Legislative Auditor within 90 days after the close of the fiscal year. The certification of revenues $50,000 or less, if applicable, is required by Louisiana Revised Statute 24:513(l)(1)(c)(i). **************************************************************************************************** Personally came and appeared before the undersigned authority, A.D. Johnson, Jr., CPA, who, duly sworn, deposes and says that the financial statements herewith given present fairly the financial position of Martin Luther King Health Center as of Mav and the results of operations for the year then ended, in accordance with the basis of accounting described within the accompanying financial statements. (Complete if applicable) In addition, A.D. Johnson, Jr., CPA, who, duly sworn, deposes and says that Martin Luther King Health Center received $50,000 or less in public revenues for the year ended Mav and accordingly, is not required to have an audit for the previously mentioned year Officer Signature Sworn to and subscribed before me this 20/5. NO"^Y PUBLIC Officer's Name A.D. Johnson, Jr., CPA Officer's Title Treasurer Underprovisionsofstatelaw,thisrepomsaAddress 333 Texas St., Ste 1525 document.acopyofthereporthasbeensubmittedto Shreveport, LA ttie entity and other appropriate public offtcia(3h7p x/ report is available avaiiaoie for TUI IJUUML, public inspection n at the -- Baton Rouge office of the Legislative Auditor and where adoropriate, at the office of the parish clerk of court. AUG Release Date com Please return the completed form within 90 davs of vour entity's vear-end to Office of Legislative Auditor - Local Government Services. Post Office Box Baton Rouge. LA

2 statement A Statement of Activities For the Year Ended May 31, 2015 General Fund other Fund Total RECEIPTS (Provide Brief Description): 1.Local grant - Caddo Parish Commission $10,000 $ $10,000 2.Federal grant - ACA Navigator 39,465 39, State grant Total receipts (add lines 1-5) $10,000 $39,971 $49,971 DISBURSEMENTS (Provide Brief Description): 7.Contract Labor $ $14,904 $14,904 8.Personnel Costs 21,533 21, Pharmaceuticals 10, ,000 lo.prininting/marketing Office. Telephone, Internet. Utilities, Misc. 2,697 2, Mileage Reimbursement Total Disbursements (add lines 8-12) $10,000 $39,971 $49, Change In fund balance (Lines 6 minus 13) $0 $0 $0 15. Fund Balance at beginning of year $0 $0 $0 16, Fund balance (deficit) at end of year (Add lines 14-15) -This amount also goes on line 12, Statement B $0 $0 $0 PLEASE RETAIN A COPY OF THE COMPLETED FINANCIAL STATEMENTS FOR YOUR RECORDS Please return the completed form within 90 davs of vour entity's vear-end to Office of Legislative auditor - Local Government Services. Post Office Box Baton Rouge, LA

3 statement B Statement of Financial Position on May 31, 2015 General Other Fund Fund Total ASSETS (balances at year-end) -Give brief description: 1. Cash and cash equivalents on hand $0 $0 $0 2. Office furnishings (Cost of desks, etc). Equipment 3^ Other (brief description)prepaids. promises to give 6. Total Assets (add lines 1-5) $0 $0 $0 LIABILITIES AND FUND BALANCE (at year-end): 7. Liabilities (give brief description): a $0 $0 $ Total Liabilities (add lines 7-10) 12. Fund balance (amount from Line 16 on Statement A) 13. Other 14. Total Liabilities and Fund Balance (add lines 11-13) $0 $0 $0 PLEASE RETAIN A COPY OF THE COMPLETED FINANCIAL STATEMENTS FOR YOUR RECORDS Please return the completed form within 90 days of your entity's year-end to Office of Legislative auditor - Local Government Services. Post Office Box Baton Rouge. LA

4 statement C Schedule of Compensation, Benefits and Other Payments to Agency Head or Chief Executive Officer Agency Head Name/Title: Janet Mentesane Purpose Amount Salary 8,816 Benefits-insurance Benefits-retirement 881 Benefits-other Health Insurance 791 Benefits-other (describe) Benefits-other (describe) Car allowance Vehicle provided by govemment (enter amount reported on W-2) Per diem Reimbursements-Mileage/Cell Phone 153 Travel Registration f^s Conference travel Housing Unvouchered expenses (example:- travel advances, etc.) Special meals Other

5 July 6, 2015 The accompanying Statement of Financial Position of as of May 31, 2015 and the related Statement of Activities for the year ended May 31, 2015, have been prepared by A.D. Johnson, Jr., CPA. I have prepared such financial statements in my capacity as treasurer for.