Opioid Settlement Funds Report Form – Idaho Office of Attorney General

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
Information About the Person Submitting this Report
Entity Name*
Respondent's Name*
First Last
Title*
Phone Number*
Email*
Enter Email Confirm Email
Should all future opioid related correspondence go to you?*
Should all future opioid related correspondence go to you?
Hidden
Correspondent Name*
First Last
Hidden
Title*
Hidden
Correspondent's Email*
Enter Email Confirm Email
PAYMENTS RECEIVED
Information about payments the subdivision received (All information required)
Payments the Subdivision Received

(All information required)
Funds balance at the end of FY 2022*
Funds balance at the end of FY 2022 - (July 1, 2021 - June 30, 2022)
Settlement funds received in FY 2023*
Settlement funds received in FY 2023 - (July 1, 2022 - June 30, 2023)
Settlement funds expended in FY 2023*
Settlement funds expended in FY 2023
Settlement funds balance at end of FY 2023*
Settlement funds balance at end of FY 2023 - (June 30, 2023)
Details about Funds Received During the Fiscal Year

(All information required)
Payment Date*
Payment Date (1)

MM slash DD slash YYYY
Payment Amount*
Payment Amount Received (1)
Source of Payments*
Source of Payments (1)
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Payment Date
Payment Date (2)
MM slash DD slash YYYY
Payment Amount
Payment Amount Received (2)
Source of Payments
Source of Payments (2)
-
Payment Date
Payment Date (3)
MM slash DD slash YYYY
Payment Amount
Payment Amount Received (3)
Source of Payments
Source of Payments (3)
-
Payment Date
Payment Date (4)
MM slash DD slash YYYY
Payment Amount
Paymnet Amount Received (4)
Source of Payments
Source of Payments (4)
-
Payment Date
Payment Date (5)
MM slash DD slash YYYY
Payment Amount
Payment Amount Received (5)
Source of Payments
Source of Payments (5)
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Total Amount Recieved
Total Amount Received
Information about Funds Expended on Approved Uses (EXHIBIT A)

(All information required)
Entity Expend Funds*
Did the Entity expend funds during the fiscal year?

Yes

No
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Approved Use Section
Approved Use Section (1)
Approved Use Subsection
Approved Use Subsection (1)
Payment Amount
Payment Amount Disbursed (1)
-
Approved Use Section
Approved Use Section (2)
Approved Use Subsection
Approved Use Subsection (2)
Payment Amount
Payment Amount Disbursed (2)
-
Approved Use Section
Approved Use Section (3)
Approved Use Subsection
Approved Use Subsection (3)
Payment Amount
Payment Amount Disbursed (3)
-
Approved Use Section
Approved Use Section (4)
Approved Use Subsection
Approved Use Subsection (4)
Payment Amount
Payment Amount Disbursed (4)
-
Approved Use Section
Approved Use Section (5)
Approved Use Subsection
Approved Use Subsection (5)
Payment Amount
Payment Amount Disbursed (5)
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Total Amount Disbursed
Total Amount Disbursed
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File Uploads
Uploaded Copies*
I can upload copies of the subdivision's budget sections or resolution(s) that support the subdivision's disbursements.

Yes

No
Subdivision Disbursement Files
Please provide any documentation you believe supports your response.
(Maximum 3 files @ 10MB each.)

Drop files here or

Max. file size: 10 MB, Max. files: 3.
Reason*
If "No", Explain why the required documents are not attached.
Uploaded Other Copies
I can upload copies of the other supporting records that the subdivision wants the Attorney General's Office and public to review.

Yes

No
Other Supporting Files
Please provide any documentation you believe supports your response.
(Maximum 2 files @ 10MB each.)

Drop files here or

Max. file size: 10 MB, Max. files: 3.
Public Records Act Notice

This report and all uploaded documents are public records and will be published on the Attorney General’s website at ag.idaho.gov. The Attorney General also will provide a copy of the report and all uploaded documents to the opioid settlement administrator and anyone who submits a public record request.
Acknowledgements

TBy typing my name below, I warrant that: (a) all information provided in this report is true and correct, (b) all opioid settlement funds expended by the subdivision were expended on approved uses as provided in Exhibit A, and (c) I have the necessary authority to sign and submit this report on behalf of the subdivision.
SIgnature*
Signature
Date*
Date

MM slash DD slash YYYY
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CAPTCHA

Opioid Settlement Fund Report

Payments the Subdivision Received

Details about Funds Received During the Fiscal Year

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Information about Funds Expended on Approved Uses (EXHIBIT A)

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File Uploads

Public Records Act Notice

Acknowledgements

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