Home Opioid Settlement Funds Report Form Opioid Settlement Fund Report Opioid Settlement Fund Report Please note that ALL fields below are required for submission. THIS IS NOT A REAL FORM - THIS IS FOR TESTING PURPOSES ONLY Opioid Fund Annual Financial Report Fiscal Year Ending* Name of Subdivision* Information About the Person Submitting this Report (The person completing this report must have authority to provide financial information on behalf of the subdivision.)Respondent's Name* -- Select One --Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Title* Address* Mailing Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Enter Email Confirm Email Required Financial Information(Paragraph D.4. of the Idaho Opioid Settlement Intrastate Allocation Agreement requires all subdivisions that hold opioid settlement funds to provide the following information every fiscal year) What was the subdivision's opioid settlement fund balance at the end of the prior fiscal year?*What was the subdivision's opioid settlement fund balance at the end of the prior fiscal year? How much in total opioid settlement funds did the subdivision receive during the fiscal year?*How much in total opioid settlement funds did the subdivision receive during the fiscal year? What was the subdivision's opioid settlement fund balance at the end of the fiscal year?*What was the subdivision's opioid settlement fund balance at the end of the fiscal year?-Itemization of Fiscal Year Disbursements(If the subdivision spent any opioid settlement funds during the fiscal year, it must provide an itemization of amounts spent and identify the approved purposes from Exhibit A.) How many disbursements of opioid settlement funds did the subdivision make during the current fiscal year?*How many disbursements of opioid settlement funds did the subdivision make during the current fiscal year?012345678910-Disbursement (1)*Disbursement (1)Disbursement (1) - Exhibit A Section*Disbursement (1) - Exhibit A Section Disbursement (1) - Exhibit A Paragraph*Disbursement (1) - Exhibit A Paragraph -Disbursement (2)*Disbursement (2)Disbursement (2) - Exhibit A Section*Disbursement (2) - Exhibit A Section Disbursement (2) - Exhibit A Paragraph*Disbursement (2) - Exhibit A Paragraph -Disbursement (3)*Disbursement (3)Disbursement (3) - Exhibit A Section*Disbursement (3) - Exhibit A Section Disbursement (3) - Exhibit A Paragraph*Disbursement (3) - Exhibit A Paragraph -Disbursement (4)*Disbursement (4)Disbursement (4) - Exhibit A Section*Disbursement (4) - Exhibit A Section Disbursement (4) - Exhibit A Paragraph*Disbursement (4) - Exhibit A Paragraph -Disbursement (5)*Disbursement (5)Disbursement (5) - Exhibit A Section*Disbursement (5) - Exhibit A Section Disbursement (5) - Exhibit A Paragraph*Disbursement (5) - Exhibit A Paragraph -Disbursement (6)*Disbursement (6)Disbursement (6) - Exhibit A Section*Disbursement (6) - Exhibit A Section Disbursement (6) - Exhibit A Paragraph*Disbursement (6) - Exhibit A Paragraph -Disbursement (7)*Disbursement (7)Disbursement (7) - Exhibit A Section*Disbursement (7) - Exhibit A Section Disbursement (7) - Exhibit A Paragraph*Disbursement (7) - Exhibit A Paragraph -Disbursement 8)*Disbursement (8)Disbursement (8) - Exhibit A Section*Disbursement (8) - Exhibit A Section Disbursement (8) - Exhibit A Paragraph*Disbursement (8) - Exhibit A Paragraph -Disbursement (9)*Disbursement (9)Disbursement (9) - Exhibit A Section*Disbursement (9) - Exhibit A Section Disbursement (9) - Exhibit A Paragraph*Disbursement (9) - Exhibit A Paragraph -Disbursement (10)*Disbursement (10)Disbursement (10) - Exhibit A Section*Disbursement (10) - Exhibit A Section Disbursement (10) - Exhibit A Paragraph*Disbursement (10) - Exhibit A Paragraph -Public Records Act Notice The information the subdivision submits to the Attorney General’s Office is a public record and is made publicly available on the Attorney General’s website at ag.idaho.gov. Acknowledgements By typing my name in the box below and submitting this form, I certify the information in this form is true and correct to the best of my knowledge, and I am authorized to sign on behalf of the subdivision. SIgnature*Signature Date*Date MM slash DD slash YYYY -CAPTCHA
