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A - FPPC Forms
For complete details of all FPPC forms: FPPC website: www.fppc.ca.gov or call for toll -free advice 1(866) ASK -FPPC (275 -3772) All forms can be filled out using the interactive forms on -line or use the forms provided on the flash drive Forms (All Documents on Flash Drive & Hard Copy) Form 501, Candidate Intention Statement Form 410, Statement of Organization Recipient Committee Form 460, Recipient Committee Campaign Statement Form 470, Officeholder & Candidate Campaign Statement - Short Form and Supplement Form 700 - Statement of Economic Interests C ) 1 / oLOOC�C��1 Form 501, Candidate Intention Statement C C C C rte+ C td a vi Q N p a+ E C O 4N L O aV m m 'n p O P 0p 0 p C a p` +L 3 � LL> a T u a \ u a) C o o a c aai r axi E� °° •-, ° Oo v.0 L o f 10• N a '^ET�mX'�,rmcuuvoim °acro a a.0 w .�� O L E i O. 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NAME OF FILER (LAST) (FIRST) (MIDDLE) 1. Office, Agency, or Court Agency Name (Do not use acronyms) Division, Board, Department, District, if applicable Your Position ► If filing for multiple positions, list below or on an attachment. (Do not use acronyms) Agency: 2. Jurisdiction of Office (Check at least one box) ❑ State ❑ Multi- County ❑ City of 3. Type of Statement (Check at least one box) ❑ Annual: The period covered is January 1, 2014, through December 31, 2014. -or- The period covered is I through December 31, 2014. ❑ Assuming Office: Date assumed I I ❑ Candidate: Election year Schedule Summary Check applicable schedules or "None." ❑ Schedule A -1 - Investments — schedule attached ❑ Schedule A -2 - Investments — schedule attached ❑ Schedule B - Real Property — schedule attached Position: ❑ Judge or Court Commissioner (Statewide Jurisdiction) ❑ County of ❑ Other ❑ Leaving Office: Date Left (Check one) O The period covered is January 1, 2014, through the date of leaving office. O The period covered is _ the date of leaving office. and office sought, if different than Part 1: ► Total number of pages including this cover page: through ❑ Schedule C - Income, Loans, & Business Positions — schedule attached ❑ Schedule D - Income — Gifts — schedule attached ❑ Schedule E - Income - Gifts - Travel Payments - schedule attached .or- F-1 None - No reportable interests on any schedule 5. Verification MAILING ADDRESS STREET CITY STATE ZIP CODE (Business or Agency Address Recommended - Public Document) DAYTIME TELEPHONE NUMBER E -MAIL ADDRESS ) I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I acknowledge this is a public document. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. err Date Signed Signature (month, day, year) (File the originally signed statement with your filing official.) FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions Cover Page 'Enter your name, mailing address, and daytime telephone *awnumber in the spaces provided. Because the Form 700 is a public document, you may list your business /office address instead of your home address. Part 1. Office, Agency, or Court • Enter the name of the office sought or held, or the agency or court. Consultants must enter the public agency name rather than their private firm's name. (Examples: State Assembly; Board of Supervisors; Office of the Mayor; Department of Finance; Hope County Superior Court) • Indicate the name of your division, board, or district, if applicable. (Examples: Division of Waste Management; Board of Accountancy; District 45). Do not use acronyms. • Enter your position title. (Examples: Director; Chief Counsel; City Council Member; Staff Services Analyst) • If you hold multiple positions (i.e., a city council member who also is a member of a county board or commission), you may be required to file statements with each agency. To simplify your filing obligations, you may complete an expanded statement. • To do this, enter the name of the other agency(ies) with which you are required to file and your position title(s) in the space provided. Do not use acronyms. Attach an additional sheet if necessary. Complete one statement covering the disclosure requirements for all positions. Each copy must contain an original signature. Therefore, before signing the statement, make a copy for each agency. Sign each copy with an original signature and file with each agency. If you assume or leave a position after a filing deadline, you must complete a separate statement. For example, a city council member who assumes a position with a county special district after the April 1 annual filing deadline must file a separate assuming office statement. In subsequent years, the city council member may expand his or her annual filing to include both positions. Example: Scott Baker is a city council member for the City of Lincoln and a board member for the Camp Far West Irrigation District — a multi- county agency that covers Placer and Yuba counties. Scott will complete one Form 700 using full disclosure (as required for the city position) and covering interests in both Placer and Yuba counties (as required for the multi- county position) and list both positions on the Cover Page. Before signing the statement, Scott will make a copy and sign both statements. One statement will be filed with City of Lincoln and the other will be filed with Camp Far West Irrigation District. Both will contain an original signature. Part 2. Jurisdiction of Office • Check the box indicating the jurisdiction of your agency and, if applicable, identify the jurisdiction. Judges, judicial candidates, and court commissioners have statewide jurisdiction. All other filers should review the Reference Pamphlet, page 13, to determine their jurisdiction. • If your agency is a multi - county office, list each county in which your agency has jurisdiction. • If your agency is not a state office, court, county office, city office, or multi- county office (e.g., school districts, special districts and JPAs), check the "other" box and enter the county or city in which the agency has jurisdiction. Example: This filer is a member of a water district board with jurisdiction in portions of Yuba and Sutter Counties. Part 3. Type of Statement 1. office, Agency, or Court Agency Nave (Do W use acronyms) DrviNm. Board, DepeNnmi. Diablo. a applicable Yoa Poaitim . If filing for multiple positions, tiN bebw a m an attachment. (Do not use amnyms) Agency: Position: 2. Jurisdiction of office (Cheat/ at teat — b.) ❑ State ❑ Judge a Court C— Masiow (Sleteeide JuhEictim) ® mug C aay Yuba & Sutter Counties p C-gy of ❑ City d ❑ omer Check at least one box. The period covered by a statement is determined by the type of statement you are filing. If you are completing a 2014 annual statement, do not change the pre - printed dates to reflect 2015. Your annual statement is used for reporting the previous year's economic interests. Economic interests for your annual filing covering January 1, 2015, through December 31, 2015, will be disclosed on your statement filed in 2016. See Reference Pamphlet, page 4. Combining Statements: Certain types of statements may be combined. For example, if you leave office after January 1, but before the deadline for filing your annual statement, you may combine your annual and leaving office statements. File by the earliest deadline. Consult your filing officer or the FPPC. Part 4. Schedule Summary • Enter the total number of completed pages including the cover page and either check the box for each schedule you use to disclose interests; or if you have nothing to disclose on any schedule, check the "No reportable interests" box. Please do not attach any blank schedules. Part 5. Verification Complete the verification by signing the statement and entering the date signed. All statements must have an original "wet" signature or be duly authorized by your filing officer to file electronically under Government Code Section 87500.2. Instructions, examples, FAQs, and a reference pamphlet are available to help answer your questions. When you sign your statement, you are stating, under penalty of perjury, that it is true and correct. Only the filer has authority to sign the statement. An unsigned statement is not considered filed and you may be subject to late filing penalties. FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions —1 SCHEDULE A -1 Investments Stocks, Bonds, and Other Interests (Ownership Interest is Less Than 10 %) Do not attach brokerage or financial statements. ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF BUSINESS ACTIVITY FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership 0 Income Received of $0 - $499 0 Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: / 12 / 12 ACQUIRED DISPOSED ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF BUSINESS ACTIVITY FAIR MARKET VALUE tir.W ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 cm NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership Q Income Received of $0 - $499 Q Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: I/ 12 _J 1 12 ACQUIRED DISPOSED ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF BUSINESS ACTIVITY FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership Q Income Received of $0 - $499 0 Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: / 12 _/ 12 ACQUIRED DISPOSED Comments: CALIFORNIA FORM 700 FAIR POLITICAL PRACTICES COMMISSION ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF BUSINESS ACTIVITY FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership Q Income Received of $0 - $499 O Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: � / 12 / 12 ACQUIRED DISPOSED ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF BUSINESS ACTIVITY FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership Q Income Received of $0 - $499 Q Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: / 12 / 12 ACQUIRED DISPOSED Print Name Office, Agency or Court Statement Type ❑ 2012/2013 Annual [:]Assuming ❑ Leaving ❑ Annual ❑ Candidate (yr) I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed Filer's Signature (month, day, FPPC Form 700 Amendment (2012/2013) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — Schedules A -1 and A -2 Investments Investment" means a financial interest in any business entity that is located in, doing business in, planning to do business in, or that has done business during the previous two years in your agency's jurisdiction in which you, your spouse or registered domestic partner, or your dependent children had a direct, indirect, or beneficial interest totaling $2,000 or more at any time during the reporting period. See Reference Pamphlet, page 13. Reportable investments include: • Stocks, bonds, warrants, and options, including those held in margin or brokerage accounts and managed investment funds (See Reference Pamphlet, page 13.) • Sole proprietorships • Your own business or your spouse's or registered domestic partner's business (See Reference Pamphlet, page 8, for the definition of "business entity. ") • Your spouse's or registered domestic partner's investments that are legally separate property • Partnerships (e.g., a law firm or family farm) • Investments in reportable business entities held in a retirement account (See Reference Pamphlet, page 15.) • If you, your spouse or registered domestic partner, and dependent children together had a 10% or greater ownership interest in a business entity or trust (including a living trust), you must disclose investments held by the business entity or trust. See Reference Pamphlet, page 15, for more information on disclosing trusts. • Business trusts You are not required to disclose: • Insurance policies, government bonds, diversified mutual funds, certain funds similar to diversified mutual funds (such as exchange traded funds) and investments held in certain retirement accounts. See Reference Pamphlet, page 12, for detailed information. (Regulation 18237) • Bank accounts, savings accounts, money market accounts and certificates of deposits • Insurance policies • Annuities • Commodities • Shares in a credit union • Government bonds (including municipal bonds) Reminders • Do you know your agency's jurisdiction? • Did you hold investments at any time during the period covered by this statement? • Code filers — your disclosure categories may only require disclosure of specific investments. Retirement accounts invested in non - reportable interests (e.g., insurance policies, diversified mutual funds, or government bonds) (See Reference Pamphlet, page 15.) Government defined - benefit pension plans (such as CalPERS and CaISTRS plans) Interests held in a blind trust (See Reference Pamphlet, page 16.) Use Schedule A -1 to report ownership of less than 10% (e.g., stock). Schedule C (Income) may also be required if the investment is not a stock or corporate bond. See second example below. Use Schedule A -2 to report ownership of 10% or greater (e.g., a sole proprietorship). To Complete Schedule A -1: Do not attach brokerage or financial statements. • Disclose the name of the business entity. • Provide a general description of the business activity of the entity (e.g., pharmaceuticals, computers, automobile manufacturing, or communications). • Check the box indicating the highest fair market value of your investment during the reporting period. If you are filing a candidate or an assuming office statement, indicate the fair market value on the filing date or the date you took office, respectively. • Identify the nature of your investment (e.g., stocks, warrants, options, or bonds). • An acquired or disposed of date is only required if you initially acquired or entirely disposed of the investment interest during the reporting period. The date of a stock dividend reinvestment or partial disposal is not required. Generally, these dates will not apply if you are filing a candidate or an assuming office statement. Examples: John Smith holds a state agency position. His conflict -of- interest code requires full disclosure of investments. John must disclose his stock holdings of $2,000 or more in any company that does business in California, as well as those stocks held by his spouse or registered domestic partner and dependent children. Susan Jones is a city council member. She has a 4% interest, worth $5,000, in a limited partnership located in the city. Susan must disclose the partnership on Schedule A -1 and income of $500 or more received from the partnership on Schedule C. FPPC Form 700 (2012/2013) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 7 SCHEDULE A -2 Investments, Income, and Assets of Business Entities/Trusts (Ownership Interest is 10% or Greater) Name Address (Business Address Acceptable) Check one ❑ Trust, go to 2 ❑ Business Entity, complete the box, then go to 2 GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $0 - $1,999 ❑ $2,000 - $10,000 /14 /14 ❑ $10,001 - $100,000 ACQUIRED DISPOSED ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Partnership ❑ Sole Proprietorship ❑ they II YOUR BUSINESS POSITION III ❑ $0 - $499 ❑ $500 - $1,000 ❑ $1,001 - $10,000 None or ❑ $10,001 - $100,000 ❑ OVER $100,000 Names listed below c;necK one oox: ❑ INVESTMENT ❑ REAL PROPERTY Name of Business Entity, if Investment, or Assessor's Parcel Number or Street Address of Real Property Description of Business Activity or City or Other Precise Location of Real Property FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $2,000 - $10,000 El $10,001 - $100,000 14 ❑ $100,001 - $1,000,000 ACQUIRED DISPOSED ❑ Over $1,000,000 NATURE OF INTEREST ❑ Property Ownership /Deed of Trust ❑ Stock ❑ Partnership ❑ Leasehold ❑ Other Yrs. remaining ❑ Check box if additional schedules reporting investments or real property are attached Comments: Print Name Office, Agency or Court Statement Type ❑ 2014/2015 Annual ❑ Annual ❑ Assuming (yd ❑ Leaving ❑ Candidate I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed (month, day, year) Filer's Signature FPPC Form 700 (2014/201S) Sch. A-2 FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — Schedule A -2 Investments, Income, and Assets of Business Entities/Trusts `''Use Schedule A -2 to report investments in a business entity (including a consulting business or other independent contracting business) or trust (including a living trust) in which you, your spouse or registered domestic partner, and your dependent children together had a 10% or greater interest during the reporting period and which is located in, doing business in, planning to do business in, or which has done business during the previous two years in your agency's jurisdiction. See Reference Pamphlet, page 13. A trust located outside your agency's jurisdiction is reportable if it holds assets that are located in or doing business in the jurisdiction. Do not report a trust that contains non - reportable interests. For example, a trust containing only your personal residence not used in whole or in part as a business, your savings account, and some municipal bonds, is not reportable. Also report on Schedule A -2 investments and real property held by that entity or trust if your pro rata share of the investment or real property interest was $2,000 or more during the reporting period. To Complete Schedule A -2: Part 1. Disclose the name and address of the business entity or trust. If you are reporting an interest in a business entity, check "Business Entity" and complete the box as follows: • Provide a general description of the business activity of the *Ow entity. • Check the box indicating the highest fair market value of your investment during the reporting period. • If you initially acquired or entirely disposed of this interest during the reporting period, enter the date acquired or disposed. • Identify the nature of your investment. • Disclose the job title or business position you held with the entity, if any (i.e., if you were a director, officer, partner, trustee, employee, or held any position of management). A business position held by your spouse is not reportable. Part 2. Check the box indicating your pro rata share of the gross income received by the business entity or trust. This amount includes your pro rata share of the gross income from the business entity or trust, as well as your community property interest in your spouse's or registered domestic partner's share. Gross income is the total amount of income before deducting expenses, losses, or taxes. Part 3. Disclose the name of each source of income that is located in, doing business in, planning to do business in, or that has done business during the previous two years in your agency's jurisdiction, as follows: • Disclose each source of income and outstanding loan to the business entity or trust identified in Part 1 if your pro rata share of the gross income (including your community property interest in your spouse's or registered domestic partner's share) to the business entity or trust from that source was $10,000 or more during the reporting period. See Reference Pamphlet, page 11, for examples. Income from governmental sources may be reportable if not considered salary. See Regulation 18232. Loans from commercial lending institutions made in the lender's regular course of business on terms available to members of the public without regard to your official status are not reportable. • Disclose each individual or entity that was a source of commission income of $10,000 or more during the reporting period through the business entity identified in Part 1. See Reference Pamphlet, page 8, for an explanation of commission income. You may be required to disclose sources of income located outside your jurisdiction. For example, you may have a client who resides outside your jurisdiction who does business on a regular basis with you. Such a client, if a reportable source of $10,000 or more, must be disclosed. Mark "None" if you do not have any reportable $10,000 sources of income to disclose. Using phrases such as "various clients" or "not disclosing sources pursuant to attorney - client privilege" may trigger a request for an amendment to your statement. See Reference Pamphlet, page 14, for details about requesting an exemption from disclosing privileged information. Part 4. Report any investments or interests in real property held or leased by the entity or trust identified in Part 1 if your pro rata share of the interest held was $2,000 or more during the reporting period. Attach additional schedules or use FPPC's Form 700 Excel spreadsheet if needed. • Check the applicable box identifying the interest held as real property or an investment. • If investment, provide the name and description of the business entity. • If real property, report the precise location (e.g., an assessor's parcel number or address). • Check the box indicating the highest fair market value of your interest in the real property or investment during the reporting period. (Report the fair market value of the portion of your residence claimed as a tax deduction if you are utilizing your residence for business purposes.) • Identify the nature of your interest. • Enter the date acquired or disposed only if you initially acquired or entirely disposed of your interest in the property or investment during the reporting period. FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 3 SCHEDULE B Interests in Real Property (Including Rental Income) ► ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS CITY FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INTEREST ❑ Ownership /Deed of Trust ❑ Leasehold Yrs. remaining IF APPLICABLE, LIST DATE: / 14 4 ACQUIRED DISPOSED ❑ Easement Other IF RENTAL PROPERTY, GROSS INCOME RECEIVED ❑ $0 - $499 ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 SOURCES OF RENTAL INCOME: If you own a 10% or greater interest, list the name of each tenant that is a single source of income of $10,000 or more. ❑ None ► ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS CITY FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 14 ❑ $100,001 - $1,000,000 ACQUIRED DISPOSED ❑ Over $1,000,000 NATURE OF INTEREST ❑ Ownership /Deed of Trust ❑ Easement ❑ Leasehold ❑ Yrs. remaining Other IF RENTAL PROPERTY, GROSS INCOME RECEIVED ❑ $0 - $499 ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 SOURCES OF RENTAL INCOME: If you own a 10% or greater interest, list the name of each tenant that is a single source of income of $10,000 or more. ❑ None * You are not required to report loans from commercial lending institutions made in the lender's regular course of business on terms available to members of the public without regard to your official status. Personal loans and loans received not in a lender's regular course of business must be disclosed as follows: NAME OF LENDER' ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF LENDER INTEREST RATE TERM (Months/Years) ❑ None HIGHEST BALANCE DURING REPORTING PERIOD ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 ❑ Guarantor, if applicable Comments: Print Name — Office, Agency or Court Statement Type E12014/2015 Annual ❑ Assuming ❑ Leaving ❑ Annual ❑ Candidate (yr) I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed (month, day, year) Filer's Signature FPPC Form 700 (2014/2015) Sch. B FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — Schedule B Interests in Real Property Report interests in real property located in your agency's tenant was $10,000 or more during the reporting period. If *#,,„jurisdiction in which you, your spouse or registered domestic you received a total of $10,000 or more from two or more partner, or your dependent children had a direct, indirect, or tenants acting in concert (in most cases, this will apply beneficial interest totaling $2,000 or more any time during the to married couples), disclose the name of each tenant. reporting period. See Reference Pamphlet, page 13. Otherwise, mark "None." Interests in real property include: • An ownership interest (including a beneficial ownership interest) • A deed of trust, easement, or option to acquire property • A leasehold interest (See Reference Pamphlet, page 14.) • A mining lease • An interest in real property held in a retirement account (See Reference Pamphlet, page 15.) • An interest in real property held by a business entity or trust in which you, your spouse or registered domestic partner, and your dependent children together had a 10% or greater ownership interest (Report on Schedule A -2.) • Your spouse's or registered domestic partner's interests in real property that are legally held separately by him or her You are 1ijQ1 required to report: • A residence, such as a home or vacation cabin, used exclusively as a personal residence (However, a residence in which you rent out a room or for which you claim a business deduction may be reportable. If reportable, report the fair market value of the portion claimed as a tax `,aw deduction.) Please note: A non - reportable residence can still be grounds for a conflict of interest and may be disqualifying. • Interests in real property held through a blind trust (See Reference Pamphlet, page 16, for exceptions.) To Complete Schedule B: • Report the precise location (e.g., an assessor's parcel number or address) of the real property. • Check the box indicating the fair market value of your interest in the property (regardless of what you owe on the property). • Enter the date acquired or disposed only if you initially acquired or entirely disposed of your interest in the property during the reporting period. • Identify the nature of your interest. If it is a leasehold, disclose the number of years remaining on the lease. • If you received rental income, check the box indicating the gross amount you received. • If you had a 10% or greater interest in real property and received rental income, list the name of the source(s) if your pro rata share of the gross income from any single Reminders • Income and loans already reported on Schedule B are not also required to be reported on Schedule C. • Real property already reported on Schedule A -2, Part 4 are not also required to be reported on Schedule B. • Code filers — do your disclosure categories require disclosure of real property? • Loans from a private lender that total $500 or more and are secured by real property may be reportable. Loans from commercial lending institutions made in the lender's regular course of business on terms available to members of the public without regard to your official status are not reportable. When reporting a loan: - Provide the name and address of the lender. - Describe the lender's business activity. - Disclose the interest rate and term of the loan. For variable interest rate loans, disclose the conditions of the loan (e.g., Prime + 2) or the average interest rate paid during the reporting period. The term of a loan is the total number of months or years given for repayment of the loan at the time the loan was established. - Check the box indicating the highest balance of the loan during the reporting period. - Identify a guarantor, if applicable. If you have more than one reportable loan on a single piece of real property, report the additional loan(s) on Schedule C. Example: Joe Nelson is a city planning commissioner. Joe received rental income of $12,000 during the reporting period from a single tenant who ► ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS 4600 24th Street City Henry Wells rented property Joe owned FAIR MARKET VALUE IF APPLICABLE. LIST DATE: in the city's jurisdiction. If Joe ° $9.000-$10.000 y had received the $12,000 from two o or more t tenants' names would not be required as long as no single tenant p paid $ A married couple would be tenant. considered a single t OF RENTAL INCOME: N you own a 10X a freeMr inbrm4 ITN tlro name d eeM MneM Aal la a alrpb eW� d ma d slo.00 a mom. °Nor. Henry Wells NAME OF LENDER' Sophia Petroillo ADDRESS IS--A W) 2121 Blue Sky Parkway, Sacramento BUSINESS ACTIVITY. IF ANY. OF LENDER Restaurant Owner INTEREST RATE TERM (.— /Yeen) 8 % °,N,1e 15 Years HIGHEST BALANCE WRING REPORTING PERIOD ° fsw - $1,000 ° $1.001 - sm= ® fIO,GGI - $IOO.OD0 ° OVER f100.ODO ° Guemmor, M applNxMe FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 4 SCHEDULE C Income, Loans, & Business Positions (Other than Gifts and Travel Payments) NAME OF SOURCE OF INCOME ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE YOUR BUSINESS POSITION GROSS INCOME RECEIVED ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 CONSIDERATION FOR WHICH INCOME WAS RECEIVED ❑ Salary ❑ Spouse's or registered domestic partner's income (For self - employed use Schedule A -2.) ❑ Partnership (Less than 10% ownership. For 10% or greater use Schedule A -2.) ❑ Sale of (Real property, car, boat, etc.) ❑ Loan repayment ❑ Commission or ❑ Rental Income, list each source of $10,000 or more ❑ Other (Describe) (Describe) NAME OF SOURCE OF INCOME ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE YOUR BUSINESS POSITION GROSS INCOME RECEIVED ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 CONSIDERATION FOR WHICH INCOME WAS RECEIVED ❑ Salary ❑ Spouse's or registered domestic partner's income (For self - employed use Schedule A -2.) ❑ Partnership (Less than 10% ownership. For 10% or greater use Schedule A -2.) ❑ Sale of ❑ Loan repayment (Real property, car, boat, etc.) ❑ Commission or ❑ Rental Income, list each source of $10,000 or more ❑ Other (Describe) (Describe) Comments: 0 2 LOANS RECEIVED OR OUTSTANDING DURING THE REPORTING PERIOD * You are not required to report loans from commercial lending institutions, or any indebtedness created as part of a retail installment or credit card transaction, made in the lender's regular course of business on terms available to members of the public without regard to your official status. Personal loans and loans received not in a lender's regular course of business must be disclosed as follows: NAME OF LENDER' INTEREST RATE TERM (Months/Years) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF LENDER HIGHEST BALANCE DURING REPORTING PERIOD ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 Print Name % ❑ None SECURITY FOR LOAN ❑ None ❑ Personal residence ❑ Real Property ❑ Guarantor Street address city ❑ Other (Describe) Office, Agency or Court Statement Type ❑ 2014/2015 Annual ❑ (y) Annual ❑ Assuming ❑ Leaving ❑ Candidate r I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed year) (month, day, ler's Signature y, FPPC Form 700 (2014/2015) 5ch. C FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — Schedule C Income, Loans, & Business Positions (income Other Than Gifts and Travel Payments) `%✓Reporting Income: Report the source and amount of gross income of $500 or more you received during the reporting period. Gross income is the total amount of income before deducting expenses, losses, or taxes and includes loans other than loans from a commercial lending institution. See Reference Pamphlet, page 11. You must also report the source of income to your spouse or registered domestic partner if your community property share was $500 or more during the reporting period. A source of income must be reported only if the source is located in, doing business in, planning to do business in, or has done business during the previous two years in your agency's jurisdiction. See Reference Pamphlet, page 13, for more information about doing business in the jurisdiction. Reportable sources of income may be further limited by your disclosure category located in your agency's conflict of interest code. Reporting Business Positions: You must report your job title with each reportable business entity even if you received no income during the reporting period. Use the comments section to indicate that no income was received. Commonly reportable income and loans include: • Salary/wages, per diem, and reimbursement for expenses including travel payments provided by your employer ``�"" • Community property interest (50 %) in your spouse's or registered domestic partner's income - report the employer's name and all other required information • Income from investment interests, such as partnerships, reported on Schedule A -1 • Commission income not required to be reported on Schedule A -2 (See Reference Pamphlet, page 8.) • Gross income from any sale, including the sale of a house or car (Report your pro rata share of the total sale price.) • Rental income not required to be reported on Schedule B • Prizes or awards not disclosed as gifts • Payments received on loans you made to others, including loan repayments from a campaign committee (including a candidate's own campaign committee) • An honorarium received prior to becoming a public official (See Reference Pamphlet, page 10, concerning your ability to receive future honoraria.) • Incentive compensation (See Reference Pamphlet, page 12.) Reminders • Code fliers — your disclosure categories may not require disclosure of all sources of income. • If you or your spouse or registered domestic partner are self - employed, report the business entity on Schedule A -2. • Do not disclose on Schedule C income, loans, or business positions already reported on Schedules A -2 or B. You are not required to report: • Salary, reimbursement for expenses or per diem, or social security, disability, or other similar benefit payments received by you or your spouse or registered domestic partner from a federal, state, or local government agency. • Stock dividends and income from the sale of stock unless the source can be identified. • Income from a PIERS retirement account. See Reference Pamphlet, page 11, for more exceptions to income reporting. To Complete Schedule C: Part 1. Income Received /Business Position Disclosure • Disclose the name and address of each source of income or each business entity with which you held a business position. • Provide a general description of the business activity if the source is a business entity. • Check the box indicating the amount of gross income received. • Identify the consideration for which the income was received. • For income from commission sales, check the box indicating the gross income received and list the name of each source of commission income of $10,000 or more. See Reference Pamphlet, page 8. Note: If you receive commission income on a regular basis or have an ownership interest of 10% or more, you must disclose the business entity and the income on Schedule A -2. • Disclose the job title or business position, if any, that you held with the business entity, even if you did not receive income during the reporting period. Part 2. Loans Received or Outstanding During the Reporting Period • Provide the name and address of the lender. • Provide a general description of the business activity if the lender is a business entity. • Check the box indicating the highest balance of the loan during the reporting period. • Disclose the interest rate and the term of the loan. For variable interest rate loans, disclose the conditions of the loan (e.g., Prime + 2) or the average interest rate paid during the reporting period. The term of the loan is the total number of months or years given for repayment of the loan at the time the loan was entered into. • Identify the security, if any, for the loan. FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 5 ,%W SCHEDULE D Income — Gifts ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) Comments: ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) $ Verification Print Name Office, Agency or Court Statement Type ❑ 2014/2015 Annual ❑ Assuming ❑ Leaving ❑ Annual ❑ Candidate (yr) I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed (month, day, year) Filer's Signature FPPC Form 700 (2014/2015) Sch. D FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions - Schedule D Income - Gifts 4 gift is anything of value for which you have not provided 'vavaqual or greater consideration to the donor. A gift is reportable if its fair market value is $50 or more. In addition, multiple gifts totaling $50 or more received during the reporting period from a single source must be reported. It is the acceptance of a gift, not the ultimate use to which it is put, that imposes your reporting obligation. Except as noted below, you must report a gift even if you never used it or if you gave it away to another person. If the exact amount of a gift is unknown, you must make a good faith estimate of the item's fair market value. Listing the value of a gift as "over $50" or "value unknown" is not adequate disclosure. In addition, if you received a gift through an intermediary, you must disclose the name, address, and business activity of both the donor and the intermediary. You may indicate an intermediary either in the "source" field after the name or in the "comments" section at the bottom of Schedule D. Commonly reportable gifts include: • Tickets /passes to sporting or entertainment events • Tickets /passes to amusement parks • Parking passes not used for official agency business • Food, beverages, and accommodations, including those provided in direct connection with your attendance at a convention, conference, meeting, social event, meal, or like gathering • Rebates /discounts not made in the regular course of business to members of the public without regard to official status • Wedding gifts (See Reference Pamphlet, page 16) • An honorarium received prior to assuming office (You may report an honorarium as income on Schedule C, rather than as a gift on Schedule D, if you provided services of equal or greater value than the payment received. See Reference Pamphlet, page 10, regarding your ability to receive future honoraria.) • Transportation and lodging (See Schedule E.) • Forgiveness of a loan received by you You are = required to disclose: • Gifts that were not used and that, within 30 days after receipt, were returned to the donor or delivered to a charitable organization or government agency without Reminders • Gifts from a single source are subject to a $440 limit during 2014. See Reference Pamphlet, page 10. • Code filers — you only need to report gifts from reportable sources. Gift Tracking Mobile Application • FPPC has created a gift tracking app for mobile devi that helps filers track gifts and provides a quick and easy way to upload the information to the Form 700. Visit FPPC's website to download the app. being claimed by you as a charitable contribution for tax purposes • Gifts from your spouse or registered domestic partner, child, parent, grandparent, grandchild, brother, sister, and certain other famly members (See Regulation 18942 for a complete list.). The exception does not apply if the donor was acting as an agent or intermediary for a reportable source who was the true donor. • Gifts of similar value exchanged between you and an individual, other than a lobbyist registered to lobby your state agency, on holidays, birthdays, or similar occasions • Gifts of informational material provided to assist you in the performance of your official duties (e.g., books, pamphlets, reports, calendars, periodicals, or educational seminars) • A monetary bequest or inheritance (However, inherited investments or real property may be reportable on other schedules.) • Personalized plaques or trophies with an individual value of less than $250 • Campaign contributions • Up to two tickets, for your own use, to attend a fundraiser for a campaign committee or candidate, or to a fundraiser for an organization exempt from taxation under Section 501(c)(3) of the Internal Revenue Code. The ticket must be received from the organization or committee holding the fundraiser. • Gifts given to members of your immediate family if the source has an established relationship with the family member and there is no evidence to suggest the donor had a purpose to influence you. (See Regulation 18943.) • Free admission, food, and nominal items (such as a pen, pencil, mouse pad, note pad or similar item) available to all attendees, at the event at which the official makes a speech (as defined in Regulation 18950(b)(2)), so long as the admission is provided by the person who organizes the event. • Any other payment not identified above, that would otherwise meet the definition of gift, where the payment is made by an individual who is not a lobbyist registered to lobby the official's state agency, where it is clear that the gift was made because of an existing personal or business relationship unrelated to the official's position and there is no evidence whatsoever at the time the gift is made to suggest the donor had a purpose to influence you. To Complete Schedule D: • Disclose the full name (not an acronym), address, and, if a business entity, the business activity of the source. • Provide the date (month, day, and year) of receipt, and disclose the fair market value and description of the gift. FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 6 cm SCHEDULE E Income — Gifts Travel Payments, Advances, and Reimbursements • Mark either the gift or income box. • Mark the "501(c)(3)" box for a travel payment received from a nonprofit 501(c)(3) organization or the "Speech" box if you made a speech or participated in a panel. These payments are not subject to the $440 gift limit, but may result in a disqualifying conflict of interest. ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE 501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE(S): —/___J— - — / —J— AMT: $ (if gift) TYPE OF PAYMENT: (must check one) ❑ Gift ❑ Income ❑ Made a Speech /Participated in a Panel ❑ Other - Provide Description ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE ❑ 501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE(S): __J—/ - __J__J— AMT: $ (if gift) TYPE OF PAYMENT: (must check one) ❑ Gift ❑ Income ❑ Made a Speech /Participated in a Panel ❑ Other - Provide Description fir. Comments: ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE n 501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE(S): AMT: $ (if gift) TYPE OF PAYMENT: (must check one) ❑ Gift ❑ Income ❑ Made a Speech /Participated in a Panel ❑ Other - Provide Description Verification Print Name Office, Agency or Court Statement Type ❑ 2014/2015 Annual ❑ Assuming ❑ Leaving ❑ Annual ❑ Candidate (yd have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed (month, day, year) Filer's Signature FPPC Form 700 (2014/2015) Sch. E FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — Schedule E Travel Payments, Advances, and Reimbursements ,'""Travel payments reportable on Schedule E include advances and reimbursements for travel and related expenses, including lodging and meals. Gifts of travel may be subject to the gift limit. In addition, certain travel payments are reportable gifts, but are not subject to the gift limit. To avoid possible misinterpretation or the perception that you have received a gift in excess of the gift limit, you may wish to provide a specific description of the purpose of your travel. See the FPPC fact sheet entitled "Limitations and Restrictions on Gifts, Honoraria, Travel, and Loans" at www.fppc.ca.gov. You are n.Q1 required to disclose: • Travel payments received from any state, local, or federal government agency for which you provided services equal or greater in value than the payments received, such as reimbursement for travel on agency business from your government agency employer. • A payment for travel from another local, state, or federal government agency and related per diem expenses when the travel is for education, training or other inter - agency programs or purposes. • Travel payments received from your employer in the normal course of your employment that are included in the income reported on Schedule C "'• A travel payment that was received from a non - profit entity exempt from taxation under Internal Revenue Code Section 501(c)(3) for which you provided equal or greater consideration, such as reimbursement for travel on business for a 501(c)(3) organization for which you are a board member. Note: Effective January, 2014, certain travel payments may not be reportable if reported on Form 801 by your agency. To Complete Schedule E: • Disclose the full name (not an acronym) and address of the source of the travel payment. • Identify the business activity if the source is a business entity. • Check the box to identify the payment as a gift or income, report the amount, and disclose the date(s). - Travel payments are gifts if you did not provide services that were equal to or greater in value than the payments received. You must disclose gifts totaling $50 or more from a single source during the period covered by the statement. When reporting travel payments that are gifts, you must provide a description of the gift and the date(s) received. Travel payments are income if you provided services that were equal to or greater in value than the payments received. You must disclose income totaling $500 or more from a single source during the period covered by the statement. You have the burden of proving the payments are income rather than gifts. When reporting travel payments as income, you must describe the services you provided in exchange for the payment. You are not required to disclose the date(s) for travel payments that are income. Example: City council member Rick Chandler is the chairman of a 501 (c)(6) trade association and the association pays for Rick's travel to attend its meetings. Because Rick is deemed to be providing equal or greater consideration for the travel payment by virtue of serving on the board, this payment may be reported as income. Payments for Rick to attend other events for which Rick is not providing services are likely considered gifts. ► NAME OF SOURCE Health Services Trade Association ADDRESS (Bu.-. Add— Aeeepfeblel 1230 K Street, Ste. 610 CITY AND STATE Sacramento, CA BUSINESS ACTIVITY, IF ANY. OF SOURCE ❑ 5011c1(3) Association of Healthcare Workers WEISI: AMT: $ m anr,�nm1 686.00 TYPE OF PAYMENT. (must check one) [3 Gift ® Income DESCRIPTION. Travel reimbursement_ for board. meeting FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions - 7 En 2014/2015 Statement of Economic Interests Form 700 A Public Document Also available on the FPPC website: • Form 700 in Excel format • Reference Pamphlet for Form 700 California Fair Political Practices Commission 428 J Street, Suite 620 • Sacramento, CA 95814 Email Advice: advice @fppc.ca.gov Toll -free advice line:1 (866) ASK -FPPC • 1 (866) 275 -3772 Telephone: (916) 322 -5660 • Website: www.fppc.ca.gov December 2014 W44'z New 1%W Gift Limit Increase The gift limit increased to $460 for calendar years 2015 and 2016. The gift limit during 2014 was $440. W4 must file: • Elected and appointed officials and candidates listed in Government Code Section 87200 • Employees, appointed officials, and consultants filing pursuant to a conflict of interest code ( "code filers "). Obtain your disclosure categories, which describe the interests you must report, from your agency; they are not part of the Form 700 • Candidates running for local elective offices that are designated in a conflict of interest code (e.g., county sheriffs, city clerks, school board trustees, and water board members) • Members of newly created boards and commissions not yet covered under a conflict of interest code Employees in newly created positions of existing agencies See Reference Pamphlet, page 3, at www.fppc.ca.gov or obtain from your filing officer. Ul4u to file: 87200 Filers State offices Z Your agency Judicial offices The clerk of your court Retired Judges Z Directly with FPPC County offices Z Your county filing official City offices Your city clerk Multi- County offices Z Your agency Code Filers — State and Local Officials, Employees, and Consultants Designated in a Conflict of Interest Code: File with your agency, board, or commission unless otherwise specified in your agency's conflict of interest code (e.g., Legislative staff files directly with FPPC). In most cases, the agency, board, or commission will retain the statements. Members of Boards and Commissions of Newly Created Agencies: File with your newly created agency or with your agency's code reviewing body. Employees in Newly Created Positions of Existing Agencies: File with your agency or with your agency's code reviewing body. See Reference Pamphlet, page 3. Candidates: File with your local elections office. How to file: The Form 700 is available at www.fppc.ca.gov. Form 700 schedules are also available in Excel format. All statements must have an original "wet" signature or be duly authorized )y your filing officer to file electronically under Government `'-*6ode Section 87500.2. Instructions, examples, FAQs, and a reference pamphlet are available to help answer your questions. W4,y. to file: Annual Statements March 2, 2015 - Elected State Officers - Judges and Court Commissioners - State Board and Commission Members listed in Government Code Section 87200 April 1, 2015 - Most other filers Individuals filing under conflict of interest codes in city and county jurisdictions should verify the annual filing date with their local filing officers. Statements postmarked by the filing deadline are considered filed on time. Assuming Office and Leaving Office Statements Most filers file within 30 days of assuming or leaving office or within 30 days of the effective date of a newly adopted or amended conflict of interest code. Exception: If you assumed office between October 1, 2014, and December 31, 2014, and filed an assuming office statement, you are not required to file an annual statement until March 1, 2016, or April 1, 2016, whichever is applicable. The annual statement will cover the day after you assumed office through December 31, 2015. See Reference Pamphlet, pages 6 and 7, for additional exceptions. Candidate Statements File no later than the final filing date for the declaration of candidacy or nomination documents. Amendments Statements may be amended at any time. You are only required to amend the schedule that needs to be revised. It is not necessary to amend the entire filed form. Obtain amendment schedules at www.fppc.ca.gov. There is no provision for filing deadline extensions unless the filer is serving in active military duty. (Regulation 18723) Statements of 30 pages or less may be faxed by the deadline as long as the originally signed paper version is sent by first class mail to the filing official within 24 hours. Introduction The Political Reform Act (Gov. Code Sections 81000- *#,,441014) requires most state and local government officials and employees to publicly disclose their personal assets and income. They also must disqualify themselves from participating in decisions that may affect their personal economic interests. The Fair Political Practices Commission (FPPC) is the state agency responsible for issuing the attached Statement of Economic Interests, Form 700, and for interpreting the law's provisions. Gift Prohibition Gifts received by most state and local officials, employees, and candidates are subject to a limit. During 2013 and 2014, the gift limit was $440 from a single source per calendar year. For years 2015 -2016, the limit increased to $460 from a single source during a calendar year. In addition, state officials, state candidates, and certain state employees are subject to a $10 limit per calendar month on gifts from lobbyists and lobbying firms registered with the Secretary of State. See Reference Pamphlet, page 10. State and local officials and employees should check with their agency to determine if other restrictions apply. Disqualification public officials are, under certain circumstances, required **swto disqualify themselves from making, participating in, or attempting to influence governmental decisions that will affect their economic interests. This may include interests they are not required to disclose (i.e., a personal residence is often not reportable, but may be disqualifying). Specific disqualification requirements apply to 87200 filers (e.g., city councilmembers, members of boards of supervisors, planning commissioners, etc.). These officials must identify orally the economic interest that creates a conflict of interest and leave the room before a discussion or vote takes place at a public meeting. For more information, consult Government Code Section 87105, Regulation 18702.5, and the Overview of the Conflict of Interest Laws at www.fppc.ca.gov. Honorarium Ban Most state and local officials, employees, and candidates are prohibited from accepting an honorarium for any speech given, article published, or attendance at a conference, convention, meeting, or like gathering. See Reference Pamphlet, page 10. Loan Restrictions Certain state and local officials are subject to restrictions on loans. See Reference Pamphlet, page 14. LIMA Post - Governmental Employment There are restrictions on representing clients or employers before former agencies. The provisions apply to elected state officials, most state employees, local elected officials, county chief administrative officers, city managers, including the chief administrator of a city, and general managers or chief administrators of local special districts and JPAs. The FPPC website has fact sheets explaining the provisions. Late Filing The filing officer who retains originally- signed or electronically filed statements of economic interests may impose on an individual a fine for any statement that is filed late. The fine is $10 per day up to a maximum of $100. Late filing penalties may be reduced or waived under certain circumstances. Persons who fail to timely file their Form 700 may be referred to the FPPC's Enforcement Division (and, in some cases, to the Attorney General or district attorney) for investigation and possible prosecution. In addition to the late filing penalties, a fine of up to $5,000 per violation may be imposed. For assistance concerning reporting, prohibitions, and restrictions under the Act: • Email questions to advice @fppc.ca.gov. • Call the FPPC toll -free at (866) 275 -3772. Form 700 is a Public Document Public Access Must Be Provided Statements of Economic Interests are public documents. The filing officer must permit any member of the public to inspect and receive a copy of any statement. • Statements must be available as soon as possible during the agency's regular business hours, but in any event not later than the second business day after the statement is received. Access to the Form 700 is not subject to the Public Records Act procedures. • No conditions may be placed on persons seeking access to the forms. • No information or identification may be required from persons seeking access. • Reproduction fees of no more than 10 cents per page may be charged. FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Introduction Types of Form 700 Filings Usuming Office Statement: *■rrf you are a newly appointed official or are newly employed in a position designated, or that will be designated, in a state or local agency's conflict of interest code, your assuming office date is the date you were sworn in or otherwise authorized to serve in the position. If you are a newly elected official, your assuming office date is the date you were sworn in. • Investments, interests in real property, and business positions held on the date you assumed the office or position must be reported. In addition, income (including loans, gifts, and travel payments) received during the 12 months prior to the date you assumed the office or position is reportable. For positions subject to confirmation by the State Senate or the Commission on Judicial Performance, your assuming office date is the date you were appointed or nominated to the position. Example: Maria Lopez was nominated by the Governor to serve on a state agency board that is subject to state Senate confirmation. The assuming office date is the date Maria's nomination is submitted to the Senate. Maria must report investments, interests in real property, and business -positions she holds on that date, and income (including `` wloans, gifts, and travel payments) received during the 12 months prior to that date. If your office or position has been added to a newly adopted or newly amended conflict of interest code, use the effective date of the code or amendment, whichever is applicable. Investments, interests in real property, and business positions held on the effective date of the code or amendment must be reported. In addition, income (including loans, gifts, and travel payments) received during the 12 months prior to the effective date of the code or amendment is reportable. Annual Statement: Generally, the period covered is January 1, 2014, through December 31, 2014. If the period covered by the statement is different than January 1, 2014, through December 31, 2014, (for example, you assumed office between October 1, 2013, and December 31, 2013 or you are combining statements), you must specify the period covered. Investments, interests in real property, business positions held, and income (including loans, gifts, and travel payments) received during the period covered by the statement must be reported. Do not change the preprinted dates on Schedules A -1, A -2, and B unless you are required to report the acquisition or disposition of an interest that did not occur in 2014. • If your disclosure category changes during a reporting period, disclose under the old category until the effective date of the conflict of interest code amendment and disclose under the new disclosure category through the end of the reporting period. Leaving Office Statement: Generally, the period covered is January 1, 2014, through the date you stopped performing the duties of your position. If the period covered differs from January 1, 2014, through the date you stopped performing the duties of your position (for example, you assumed office between October 1, 2013, and December 31, 2013, or you are combining statements), the period covered must be specified. The reporting period can cover parts of two calendar years. Investments, interests in real property, business positions held, and income (including loans, gifts, and travel payments) received during the period covered by the statement must be reported. Do not change the preprinted dates on Schedules A -1, A -2, and B unless you are required to report the acquisition or disposition of an interest that did not occur in 2014. Candidate Statement: If you are filing a statement in connection with your candidacy for state or local office, investments, interests in real property, and business positions held on the date of filing your declaration of candidacy must be reported. In addition, income (including loans, gifts, and travel payments) received during the 12 months rip or to the date of filing your declaration of candidacy is reportable. Do not change the preprinted dates on Schedules A -1, A -2, and B. Candidates running for local elective offices (e.g., county sheriffs, city clerks, school board trustees, and water district board members) must file candidate statements, as required by the conflict of interest code for the elected position. The code may be obtained from the agency of the elected position. Amendments: If you discover errors or omissions on any statement, file an amendment as soon as possible. You are only required to amend the schedule that needs to be revised; it is not necessary to refile the entire form. Obtain amendment schedules from the FPPC website at www.fppc.ca.gov. FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Types of Statements Instructions Cover Page Enter your name, mailing address, and daytime telephone ,,,,.iumber in the spaces provided. Because the Form 700 is a public document, you may list your business /office address instead of your home address. Part 1. Office, Agency, or Court • Enter the name of the office sought or held, or the agency or court. Consultants must enter the public agency name rather than their private firm's name. (Examples: State Assembly; Board of Supervisors; Office of the Mayor; Department of Finance; Hope County Superior Court) • Indicate the name of your division, board, or district, if applicable. (Examples: Division of Waste Management; Board of Accountancy; District 45). Do not use acronyms. • Enter your position title. (Examples: Director; Chief Counsel; City Council Member; Staff Services Analyst) • If you hold multiple positions (i.e., a city council member who also is a member of a county board or commission), you may be required to file statements with each agency. To simplify your fling obligations, you may complete an expanded statement. • To do this, enter the name of the other agency(ies) with which you are required to file and your position title(s) in the space provided. Do not use acronyms. Attach an additional sheet if necessary. Complete one statement covering the disclosure requirements for all positions. Each copy must contain an original signature. Therefore, before signing the statement, make a copy for each agency. Sign each copy with an original signature and file with each agency. If you assume or leave a position after a filing deadline, you must complete a separate statement. For example, a city council member who assumes a position with a county special district after the April 1 annual filing deadline must file a separate assuming office statement. In subsequent years, the city council member may expand his or her annual filing to include both positions. Example: Scott Baker is a city council member for the City of Lincoln and a board member for the Camp Far West Irrigation District — a multi- county agency that covers Placer and Yuba counties. Scott will complete one Form 700 using full disclosure (as required for the city position) and covering interests in both Placer and Yuba counties (as required for the multi- county position) and list both positions on the Cover Page. Before signing the statement, Scott will make a copy and sign both statements. One statement will be filed with City of Lincoln and the other will be filed with Camp Far West Irrigation District. Both will contain an original signature. Part 2. Jurisdiction of Office • Check the box indicating the jurisdiction of your agency and, if applicable, identify the jurisdiction. Judges, judicial candidates, and court commissioners have statewide jurisdiction. All other filers should review the Reference Pamphlet, page 13, to determine their jurisdiction. • If your agency is a multi -county office, list each county in which your agency has jurisdiction. • If your agency is not a state office, court, county office, city office, or multi -county office (e.g., school districts, special districts and JPAs), check the `other' box and enter the county or city in which the agency has jurisdiction. Example: This filer is a member of a water district board with jurisdiction in portions of Yuba and Sutter Counties. Part 3. Type of Statement 1. Office, Agency, or Court Agercy Nerve (DO nN use a yms) Di*., Board, Dep (tent, Di*kt it Mw* Your Pozgon . It filing for munple "b.,, IM b.1- or on en efth —L (DO nd um esmayms) Agency: Poeean: 2. Jurisdiction of Office (awk at w.et oea box) ❑ state ® mugCgunty Yuba & Sutter Counties ❑ Judge or Court Cum 0esiu r (stabeide Jurtedduri) ❑ C—ty d ❑ City of ❑ otw Check at least one box. The period covered by a statement is determined by the type of statement you are filing. If you are completing a 2014 annual statement, do not change the pre - printed dates to reflect 2015. Your annual statement is used for reporting the previous year's economic interests. Economic interests for your annual filing covering January 1, 2015, through December 31, 2015, will be disclosed on your statement filed in 2016. See Reference Pamphlet, page 4. Combining Statements: Certain types of statements may be combined. For example, if you leave office after January 1, but before the deadline for fling your annual statement, you may combine your annual and leaving office statements. File by the earliest deadline. Consult your fling officer or the FPPC. Part 4. Schedule Summary Enter the total number of completed pages including the cover page and either check the box for each schedule you use to disclose interests; or if you have nothing to disclose on any schedule, check the "No reportable interests" box. Please do not attach any blank schedules. Part 5. Verification Complete the verification by signing the statement and entering the date signed. All statements must have an original "wet" signature or be duly authorized by your filing officer to file electronically under Government Code Section 87500.2. Instructions, examples, FAQs, and a reference pamphlet are available to help answer your questions. When you sign your statement, you are stating, under penalty of perjury, that it is true and correct. Only the filer has authority to sign the statement. An unsigned statement is not considered filed and you may be subject to late filing penalties. FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions —1 STATEMENT OF ECONOMIC INTERESTS Date Receiveddiling Official Use Only COVER PAGE °lease type or print in ink. AME OF FILER (LAST) (FIRST) (MIDDLE) 1. Office, Agency, or Court Agency Name (Do not use acronyms) Division, Board, Department, District, if applicable Your Position ► If filing for multiple positions, list below or on an attachment. (Do not use acronyms) Agency: 2. Jurisdiction of Office (check at least one box) ❑ State ❑ Multi- County ❑ City of — 3. Type of Statement (Check at least one box) ❑ Annual: The period covered is January 1, 2014, through December 31, 2014. -or- The period covered is —l— I through **AW' December 31, 2014. ❑ Assuming Office: Date assumed I I ❑ Candidate: Election year Schedule Summary Check applicable schedules or "None." ❑ Schedule A -1 - Investments – schedule attached ❑ Schedule A -2 - Investments – schedule attached ❑ Schedule B - Real Property – schedule attached Position: ❑ Judge or Court Commissioner (Statewide Jurisdiction) ❑ County of ❑ Other ❑ Leaving Office: Date Left —J— I (Check one) O The period covered is January 1, 2014, through the date of leaving office. O The period covered is — the date of leaving office. and office sought, if different than Part 1: ► Total number of pages including this cover page: through ❑ Schedule C - Income, Loans, & Business Positions – schedule attached ❑ Schedule D - Income – Gifts – schedule attached ❑ Schedule E - Income - Gifts - Travel Payments - schedule attached -or- ❑ None - No reportable interests on any schedule 5. Verification MAILING ADDRESS STREET CITY STATE ZIP CODE (Business or Agency Address Recommended - Public Document) DAYTIME TELEPHONE NUMBER ( ) I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I acknowledge this is a public document. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signed (month, day, yeao Signature (File the originally signed statement with your filing official.) FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Which Schedule Do I Use? Common Reportable Interests Schedule A -1 Stocks, including those held in an IRA or a 401 K Schedule A -2 Business entities (including certain independent contracting), sole proprietorships, partnerships, LLCs, corporations, and trusts Schedule B Rental property in the jurisdiction Schedule C Non - governmental salaries of public official and spouse /registered domestic partner Schedule D Gifts from businesses (such as tickets to sporting or entertainment events) Schedule E Travel payments from third parties (not your employer) Common Non - Reportable Interests Schedule A -1 Insurance policies, government bonds, diversified mutual funds, certain funds similar to diversified mutual funds (such as exchange traded funds) and investments held in certain retirement accounts. See Reference Pamphlet, page 13, for detailed information. (Regulation 18237) Schedule A -2 Savings and checking accounts and annuities Schedule B A residence used exclusively as a personal residence (such as a home or vacation cabin) Schedule C Governmental salary (such as a school district) Schedule D Gifts from family members Schedule E Travel paid by your government agency Remember: ✓ Mark the "No reportable interests" box on Part 4 of the Schedule Summary on the Cover Page if you determine you have nothing to disclose and file the Cover Page only. Make sure you carefully read all instructions to ensure proper reporting. ✓ The Form 700 is a public document. • Most individuals must consult their agency's conflict of interest code for reportable interests. • Most individuals file the Form 700 with their agencies. ✓ When you file your statement, bring a copy to have date stamped for your records. FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions - 3 General Questions and Answers Investment Disclosure * "'Q. What is the reporting period for disclosing interests Q. on an assuming office statement or a candidate statement? A. On an assuming office statement, disclose all reportable investments, interests in real property, and A. business positions held on the date you assumed office. In addition, you must disclose income (including loans, gifts and travel payments) received during the 12 months prior to the date you assumed office. On a candidate statement, disclose all reportable investments, interests in real property, and business positions held on the date you file your declaration of candidacy. You must also disclose income (including loans, gifts and travel payments) received during the 12 months prior to the date you file your declaration of candidacy. Q. I hold two other board positions in addition to my position with the county. Must I file three statements of economic interests? A. Yes, three are required. However, you may complete one statement listing the county and the two boards on the Cover Page or an attachment as the agencies for which you will be filing. Report your economic interests using the largest jurisdiction and highest disclosure requirements assigned to you by the three agencies. Make two copies of the entire statement before signing it, sign each copy with an original signature, and distribute one original to the county and to each of the two boards. Remember to complete separate statements for positions that you leave or assume during the year. Q. I am a department head who recently began acting as city manager. Should I file as the city manager? A. Yes. File an assuming office statement as city manager. Persons serving as "acting," "interim," or "alternate" must file as if they hold the position because they are or may be performing the duties of the position. Q. As a designated employee, I left one state agency to work for another state agency. Must I file a leaving office statement? A. Yes. You may also need to file an assuming office statement for the new agency. I have an investment interest in shares of stock in a company that does not have an office in my jurisdiction. Must I still disclose my investment interest in this company? Probably. The definition of "doing business in the jurisdiction" is not limited to whether the business has an office or physical location in your jurisdiction. See Reference Pamphlet, page 13. Q. My spouse and I have a living trust. The trust holds rental property in my jurisdiction, our primary residence, and investments in diversified mutual funds. I have full disclosure. How is this trust disclosed? A. Disclose the name of the trust, the rental property and its income on Schedule A -2. Your primary residence and investments in diversified mutual funds registered with the SEC are not reportable. Q. I am required to report all investments. I have an IRA that contains stocks through an account managed by a brokerage firm. Must I disclose these stocks even though they are held in an IRA and I did not decide which stocks to purchase? A. Yes. Disclose on Schedule A -1 or A -2 any stock worth $2,000 or more in a business entity located in or doing business in your jurisdiction. Q. I own stock in IBM and must report this investment on Schedule A -1. I initially purchased this stock in the early 1990s; however, I am constantly buying and selling shares. Must I note these dates in the "Acquired" and "Disposed" fields? A. No. You must only report dates in the "Acquired" or "Disposed" fields when, during the reporting period, you initially purchase a reportable investment worth $2,000 or more or when you dispose of the entire investment. You are not required to track the partial trading of an investment. FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 4 Questions and Answers Continued Q. On last year's filing I reported stock in Encoe valued at $2,000-$10,000. Late last year the value of this stock fell below and remains at less than $2,000. How should this be reported on this year's statement? A. You are not required to report an investment if the value was less than $2,000 during the entire reporting period. However, because a disposed date is not required for stocks that fall below $2,000, you may want to report the stock and note in the "comments" section that the value fell below $2,000. This would be for informational purposes only; it is not a requirement. Q. We have a Section 529 account set up to save money for our son's college education. Is this reportable? "comments" section indicating that the business entity is not a reportable investment. The note would be for informational purposes only; it is not a requirement. Q. I am the sole owner of my business. Where do I disclose my income - on Schedule A -2 or Schedule C? A. Sources of income to a business in which you have an ownership interest of 10% or greater are disclosed on Schedule A -2. See Reference Pamphlet, page 8, for the definition of "business entity." 0 A. If the Section 529 account contains reportable interests (e.g., common stock valued at $2,000 or more), those interests are reportable (not the actual Section 529 account). If the account contains solely mutual funds, A. then nothing is reported. Income Disclosure Q. I reported a business entity on Schedule A -2. Clients of my business are located in several states. Must I report all clients from whom my pro rata share of income is $10,000 or more on Schedule A -2, Part 3? A. No, only the clients doing business on a regular basis in your jurisdiction must be disclosed. Q. I believe I am not required to disclose the names of clients from whom my pro rata share of income is $10,000 or more on Schedule A -2 because of their right to privacy. Is there an exception for reporting clients' names? A. Regulation 18740 provides a procedure for requesting an exemption to allow a client's name not to be disclosed if disclosure of the name would violate a legally recognized privilege under California law. This regulation may be obtained from our website at www.fppc.ca.gov. See Reference Pamphlet, page 14. Q. I am sole owner of a private law practice that is not reportable based on my limited disclosure category However, some of the sources of income to my law practice are from reportable sources. Do I have to disclose this income? My husband is a partner in a four - person firm where all of his business is based on his own billings and collections from various clients. How do I report my community property interest in this business and the income generated in this manner? If your husband's investment in the firm is 10% or greater, disclose 100% of his share of the business on Schedule A -2, Part 1 and 50% of his income on Schedule A -2, Parts 2 and 3. For example, a client of your husband's must be a source of at least $20,000 during the reporting period before her name is reported. Q. How do I disclose my spouse's or registered domestic partner's salary? A. Report the name of the employer as a source of income on Schedule C. Q. I am a doctor. For purposes of reporting $10,000 sources of income on Schedule A -2, Part 3, are the patients or their insurance carriers considered sources of income? A. If your patients exercise sufficient control by selecting you instead of other doctors, then your patients, rather than their insurance carriers, are sources of income to you. See Reference Pamphlet, page 14, for additional information. Q. I received a loan from my grandfather to purchase my home. Is this loan reportable? A. No. Loans received from family members are not reportable. ,ftp,A. Yes, even though the law practice is not reportable, reportable sources of income to the law practice of FPPC Form 700 (2014/2015) $10,000 or more must be disclosed. This information FPPC Advice Email: advice @fppc.ca.gov would be disclosed on Schedule C with a note in the FPPC Toll -Free Helpline: 866 /275 -3772 www.fppc.ca.gov Instructions — 5 Questions and Answers Continued I I am running for re- election to city council and made a personal loan to my campaign committee. Is this reportable on my Form 700? A. No, the loan is not reportable on Form 700; however, loan repayments from a campaign committee are reported on Schedule C as income. Q. Many years ago, I loaned my parents several thousand dollars, which they paid back this year. Do I need to report this loan repayment on my Form 700? A. No. Payments received on a loan made to a family member are not reportable. Real Property Disclosure Q. During this reporting period we switched our principal place of residence into a rental. I have full disclosure and the property is located in my agency's jurisdiction, so it is now reportable. Because I have not reported this property before, do I need to show an "acquired" date? A. No, you are not required to show an "acquired" date because you previously owned the property. However, you may want to note in the "comments" section that the property was not previously reported because it was used exclusively as your residence. This would be for informational purposes only; it is not a requirement. A. Yes, each spouse may make a gift valued at the gift limit during a calendar year. For example, during 2014 the gift limit was $440, so the Bensons may have given the supervisor artwork valued at no more than $880. The supervisor must identify Joe and Mary Benson as the sources of the gift. Q. I am a Form 700 filer with full disclosure. Our agency holds a holiday raffle to raise funds for a local charity. I bought $10 worth of raffle tickets and won a gift basket valued at $120. The gift basket was donated by Doug Brewer, a citizen in our city. At the same event, I bought raffle tickets for, and won a quilt valued at $70. The quilt was donated by a coworker. Are these reportable gifts? A. Because the gift basket was donated by an outside source (not an agency employee), you have received a reportable gift valued at $110 (the value of the basket less the consideration paid). The source of the gift is Doug Brewer and the agency is disclosed as the intermediary. Because the quilt was donated by an employee of your agency, it is not a reportable gift. 9 Q. My daughter is buying her first home and I am the co- signer on the loan. I won't occupy the home, but my daughter will. The home is located in my agency's A. jurisdiction. Must I report this property? A. No. Property occupied by a family member is not reportable as long as you are not receiving rental income or using the property for business purposes. Gift Disclosure Q. If I received a reportable gift of two tickets to a concert valued at $100 each, but gave the tickets to a friend because I could not attend the concert, do I have any reporting obligations? A. Yes. Since you accepted the gift and exercised discretion and control of the use of the tickets, you must disclose the gift on Schedule D. My agency is responsible for disbursing grants. An applicant (501(c)(3) organization) met with agency employees to present its application. At this meeting, the applicant provided food and beverages. Would the food and beverages be considered gifts to the employees? These employees are designated in our agency's conflict of interest code and the applicant is a reportable source of income under the code. Yes. If the value of the food and beverages consumed by any one filer, plus any other gifts received from the same source during the reporting period total $50 or more, the food and beverages would be reported using the fair market value and would be subject to the gift limit. Q. I received free admission to an educational conference related to my official duties. Part of the conference fees included a round of golf. Is the value of the golf considered informational material? A. No. The value of personal benefits, such as golf, attendance at a concert, or sporting event, are gifts subject to reporting and limits. **w Q. Mary and Joe Benson, a married couple, want to give a piece of artwork to a county supervisor. Is each spouse FPPC Form 700 (2014/2015) considered a separate source for purposes of the gift FPPC Advice Email: advice@fppc.ca.gov limit and disclosure? FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 6 Instructions — Schedules A -1 and A -2 Investments "Investment" means a financial interest in any business '*ftrentity (including a consulting business or other independent contracting business) that is located in, doing business in, planning to do business in, or that has done business during the previous two years in your agency's jurisdiction in which you, your spouse or registered domestic partner, or your dependent children had a direct, indirect, or beneficial interest totaling $2,000 or more at any time during the reporting period. See Reference Pamphlet, page 13. Reportable investments include: • Stocks, bonds, warrants, and options, including those held in margin or brokerage accounts and managed investment funds (See Reference Pamphlet, page 13.) • Sole proprietorships • Your own business or your spouse's or registered domestic partner's business (See Reference Pamphlet, page 8, for the definition of "business entity. ") • Your spouse's or registered domestic partner's investments that are legally separate property • Partnerships (e.g., a law firm or family farm) • Investments in reportable business entities held in a retirement account (See Reference Pamphlet, page 15.) • If you, your spouse or registered domestic partner, and dependent children together had a 10% or greater ownership interest in a business entity or trust (including a living trust), you must disclose investments held by the business entity or trust. See Reference Pamphlet, page 15, for more information on disclosing trusts. • Business trusts You are not required to disclose: • Insurance policies, government bonds, diversified mutual funds, certain funds similar to diversified mutual funds (such as exchange traded funds) and investments held in certain retirement accounts. See Reference Pamphlet, page 13, for detailed information. (Regulation 18237) • Bank accounts, savings accounts, money market accounts and certificates of deposits • Insurance policies • Annuities • Commodities • Shares in a credit union • Government bonds (including municipal bonds) • Retirement accounts invested in non - reportable interests (e.g., insurance policies, mutual funds, or government bonds) (See Reference Pamphlet, page 15.) Reminders • Do you know your agency's jurisdiction? • Did you hold investments at any time during the period covered by this statement? • Code filers — your disclosure categories may only require disclosure of specific investments. • Government defined - benefit pension plans (such as CalPERS and CaISTRS plans) • Certain interests held in a blind trust (See Reference Pamphlet, page 16.) Use Schedule A -1 to report ownership of less than 10% (e.g., stock). Schedule C (Income) may also be required if the investment is not a stock or corporate bond. See second example below. Use Schedule A -2 to report ownership of 10% or greater (e.g., a sole proprietorship). To Complete Schedule A -1: Do not attach brokerage or financial statements. • Disclose the name of the business entity. • Provide a general description of the business activity of the entity (e.g., pharmaceuticals, computers, automobile manufacturing, or communications). • Check the box indicating the highest fair market value of your investment during the reporting period. If you are filing a candidate or an assuming office statement, indicate the fair market value on the filing date or the date you took office, respectively. • Identify the nature of your investment (e.g., stocks, warrants, options, or bonds). • An acquired or disposed of date is only required if you initially acquired or entirely disposed of the investment interest during the reporting period. The date of a stock dividend reinvestment or partial disposal is not required. Generally, these dates will not apply if you are filing a candidate or an assuming office statement. Examples: John Smith holds a state agency position. His conflict of interest code requires full disclosure of investments. John must disclose his stock holdings of $2,000 or more in any company that does business in California, as well as those stocks held by his spouse or registered domestic partner and dependent children. Susan Jones is a city council member. She has a 4% interest, worth $5,000, in a limited partnership located in the city. Susan must disclose the partnership on Schedule A -1 and income of $500 or more received from the partnership on Schedule C. FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 7 SCHEDULE A -1 Investments Stocks, Bonds, and Other Interests (Ownership Interest is Less Than 10 %) Do not attach brokerage or financial statements. ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership Q Income Received of $0 - $499 Q Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: � / 14 14 ACQUIRED DISPOSED ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership O Income Received of $0 - $499 Q Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: / 14 �_/ 14 ACQUIRED DISPOSED ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership O Income Received of $0 - $499 O Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: I/ 14 �_� 14 ACQUIRED DISPOSED Comments: ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership O Income Received of $0 - $499 O Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: � / 14 �_/ 14 ACQUIRED DISPOSED ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership Q Income Received of $0 - $499 O Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: _I / 14 �_� 14 ACQUIRED DISPOSED ► NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Stock ❑ Other (Describe) ❑ Partnership O Income Received of $0 - $499 Q Income Received of $500 or More (Report on Schedule C) IF APPLICABLE, LIST DATE: � /14 �_�14 ACQUIRED DISPOSED FPPC Form 700 (2014/2015) Sch. A -1 FPPC Advice Email: advice@fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 wwwJppc.ca.gov Instructions — Schedule A -2 Investments, Income, and Assets of Business Entities /Trusts N%& -Use Schedule A -2 to report investments in a business entity (including a consulting business or other independent contracting business) or trust (including a living trust) in which you, your spouse or registered domestic partner, and your dependent children together had a 10% or greater interest during the reporting period and which is located in, doing business in, planning to do business in, or which has done business during the previous two years in your agency's jurisdiction. See Reference Pamphlet, page 13. A trust located outside your agency's jurisdiction is reportable if it holds assets that are located in or doing business in the jurisdiction. Do not report a trust that contains non - reportable interests. For example, a trust containing only your personal residence not used in whole or in part as a business, your savings account, and some municipal bonds, is not reportable. Also report on Schedule A -2 investments and real property held by that entity or trust if your pro rata share of the investment or real property interest was $2,000 or more during the reporting period. To Complete Schedule A -2: Part 1. Disclose the name and address of the business entity or trust. If you are reporting an interest in a business entity, check "Business Entity" and complete the box as follows: • Provide a general description of the business activity of the *,,4,•, entity. • Check the box indicating the highest fair market value of your investment during the reporting period. • If you initially acquired or entirely disposed of this interest during the reporting period, enter the date acquired or disposed. • Identify the nature of your investment. • Disclose the job title or business position you held with the entity, if any (i.e., if you were a director, officer, partner, trustee, employee, or held any position of management). A business position held by your spouse is not reportable. Part 2. Check the box indicating your pro rata share of the gross income received by the business entity or trust. This amount includes your pro rata share of the gross income from the business entity or trust, as well as your community property interest in your spouse's or registered domestic partner's share. Gross income is the total amount of income before deducting expenses, losses, or taxes. Part 3. Disclose the name of each source of income that is located in, doing business in, planning to do business in, or that has done business during the previous two years in your agency's jurisdiction, as follows: • Disclose each source of income and outstanding loan to the business entity or trust identified in Part 1 if your pro rata share of the gross income (including your community property interest in your spouse's or registered domestic partner's share) to the business entity or trust from that source was $10,000 or more during the reporting period. See Reference Pamphlet, page 11, for examples. Income from governmental sources may be reportable if not considered salary. See Regulation 18232. Loans from commercial lending institutions made in the lender's regular course of business on terms available to members of the public without regard to your official status are not reportable. • Disclose each individual or entity that was a source of commission income of $10,000 or more during the reporting period through the business entity identified in Part 1. See Reference Pamphlet, page 8, for an explanation of commission income. You may be required to disclose sources of income located outside your jurisdiction. For example, you may have a client who resides outside your jurisdiction who does business on a regular basis with you. Such a client, if a reportable source of $10,000 or more, must be disclosed. Mark "None" if you do not have any reportable $10,000 sources of income to disclose. Using phrases such as "various clients" or "not disclosing sources pursuant to attorney - client privilege" may trigger a request for an amendment to your statement. See Reference Pamphlet, page 14, for details about requesting an exemption from disclosing privileged information. Part 4. Report any investments or interests in real property held or leased by the entity or trust identified in Part 1 if your pro rata share of the interest held was $2,000 or more during the reporting period. Attach additional schedules or use FPPC's Form 700 Excel spreadsheet if needed. • Check the applicable box identifying the interest held as real property or an investment. • If investment, provide the name and description of the business entity. • If real property, report the precise location (e.g., an assessor's parcel number or address). • Check the box indicating the highest fair market value of your interest in the real property or investment during the reporting period. (Report the fair market value of the portion of your residence claimed as a tax deduction if you are utilizing your residence for business purposes.) • Identify the nature of your interest. • Enter the date acquired or disposed only if you initially acquired or entirely disposed of your interest in the property or investment during the reporting period. FPPC Form 700 (2014/2015) FPPC Advice Email: advice@fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — 9 M In SCHEDULE A -2 Investments, Income, and Assets of Business Entities /Trusts (Ownership Interest is 10% or Greater) 11- 1. BUSINESS ENTITY OR TRUST Name Address (Business Address Acceptable) Check one ❑ Trust, go to 2 ❑ Business Entity, complete the box, then go to 2 GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $0 - $1,999 ❑ $2,000 - $10,000 4 /14 ❑ $10,001 - $100,000 ACQUIRED DISPOSED ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Partnership ❑ Sole Proprietorship ❑ Other YOUR BUSINESS POSITION CROSS 1- 2 IDENTIFY THE • . (INCLUDE YOUR ••• RATA SHARE OF • SS INCOME TO THE ENTITY/TRUST) ❑ $0-$499 ❑ $10,001 - $100,000 ❑ $500 - $1,000 ❑ OVER $100,000 ❑ $1,001 - $10,000 m� 3 LIST THE NAME OF ••• TABLE SINGLE SOURCE OF INCOME OF $10.000 OR MORE ❑ None or ❑ Names listed below PROPERTY 1� 4. INVESTMENTS AND INTERESTS IN REAL • OR LEASED BY THE BUSINESS ENTITY OR TRUST Check one box: ❑ INVESTMENT ❑ REAL PROPERTY Name of Business Entity, if Investment, 2c Assessor's Parcel Number or Street Address of Real Property Description of Business Activity g[ City or Other Precise Location of Real Property FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 ❑ $100,001 - $1,000,000 ACQUIRED DISPOSED ❑ Over $1,000,000 NATURE OF INTEREST ❑ Property Ownership /Deed of Trust ❑ Stock ❑ Partnership ❑ Leasehold ❑ Other Yrs. remaining ❑ Check box if additional schedules reporting investments or real property are attached CALIFORNIA FORM 700 FAIR POLITICAL PRACTICES COMMISSION 11- 1. BUSINESS ENTITY OR Address (Business Address Acceptable) Check one ❑ Trust, go to 2 ❑ Business Entity, complete the box, then go to 2 GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $0 - $1,999 ❑ $2,000 - $10,000 �� 14 � /14 ❑ $10,001 - $100,000 ACQUIRED DISPOSED ❑ $100,001 - $1,000,000 ❑ Over $1,000,000 NATURE OF INVESTMENT ❑ Partnership ❑ Sole Proprietorship ❑ Other YOUR BUSINESS POSITION 0� 2. IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA SHARE OF •• SS INCOME TO ❑ $0-$499 ❑ $10,001 - $100,000 ❑ $500 - $1,000 ❑ OVER $100,000 ❑ $1,001 - $10,000 1- 3. LIST THE NAME OF ••• TABLE SINGLE SOURCE OF INCOME OF $10,000 OR MORE None or 0 Names listed below PROPERTY 1- 4. INVESTMENTS AND INTERESTS IN REAL • LEASED BY THE BUSINESS ENTITY •- Check one box: ❑ INVESTMENT ❑ REAL PROPERTY Name of Business Entity, if Investment, 2[ Assessor's Parcel Number or Street Address of Real Property Description of Business Activity gr City or Other Precise Location of Real Property FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 4 ❑ $100,001 - $1,000,000 ACQUIRED DISPOSED ❑ Over $1,000,000 NATURE OF INTEREST ❑ Property Ownership /Deed of Trust ❑ Stock ❑ Partnership ❑ Leasehold ❑ Other Yrs. remaining ❑ Check box if additional schedules reporting investments or real property are attached FPPC Form 700 (2014/2015) Sch. A -2 Comments: FPPC Advice Email: advice@fppc.ca.gov FPPC Toil -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions - Schedule B Interests in Real Property Report interests in real property located in your agency's tenant was $10,000 or more during the reporting period. If *,,,,,rurisdiction in which you, your spouse or registered domestic you received a total of $10,000 or more from two or more partner, or your dependent children had a direct, indirect, or tenants acting in concert (in most cases, this will apply beneficial interest totaling $2,000 or more any time during the to married couples), disclose the name of each tenant. reporting period. See Reference Pamphlet, page 13. Otherwise, mark "None." Interests in real property include: • An ownership interest (including a beneficial ownership interest) • A deed of trust, easement, or option to acquire property • A leasehold interest (See Reference Pamphlet, page 14.) • A mining lease • An interest in real property held in a retirement account (See Reference Pamphlet, page 15.) • An interest in real property held by a business entity or trust in which you, your spouse or registered domestic partner, and your dependent children together had a 10% or greater ownership interest (Report on Schedule A -2.) • Your spouse's or registered domestic partner's interests in real property that are legally held separately by him or her You are DgI required to report: • A residence, such as a home or vacation cabin, used exclusively as a personal residence (However, a residence in which you rent out a room or for which you claim a business deduction may be reportable. If reportable, report the fair market value of the portion claimed as a tax deduction.) Please note: A non - reportable residence can still be grounds for a conflict of interest and may be disqualifying. • Interests in real property held through a blind trust (See Reference Pamphlet, page 16, for exceptions.) To Complete Schedule B: • Report the precise location (e.g., an assessor's parcel number or address) of the real property. • Check the box indicating the fair market value of your interest in the property (regardless of what you owe on the property). • Enter the date acquired or disposed only if you initially acquired or entirely disposed of your interest in the property during the reporting period. • Identify the nature of your interest. If it is a leasehold, disclose the number of years remaining on the lease. • If you received rental income, check the box indicating the gross amount you received. • If you had a 10% or greater interest in real property and received rental income, list the name of the source(s) if your pro rata share of the gross income from any single Reminders • Income and loans already reported on Schedule B are not also required to be reported on Schedule C. • Real property already reported on Schedule A -2, Part 4 are not also required to be reported on Schedule B. • Code filers — do your disclosure categories require disclosure of real property? • Loans from a private lender that total $500 or more and are secured by real property may be reportable. Loans from commercial lending institutions made in the lender's regular course of business on terms available to members of the public without regard to your official status are not reportable. When reporting a loan: - Provide the name and address of the lender. - Describe the lender's business activity. - Disclose the interest rate and term of the loan. For variable interest rate loans, disclose the conditions of the loan (e.g., Prime + 2) or the average interest rate paid during the reporting period. The term of a loan is the total number of months or years given for repayment of the loan at the time the loan was established. - Check the box indicating the highest balance of the loan during the reporting period. - Identify a guarantor, if applicable. If you have more than one reportable loan on a single piece of real property, report the additional loan(s) on Schedule C. Example: Joe Nelson is a city planning commissioner. Joe received rental income of $12,000 during the reporting period ► ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS 4600 24th Street from a single tenant who crcr Henry Wells rented property Joe owned FAIR MARKET VALUE IF APPLICABLE. LIST DATE: in the city's jurisdiction. If Joe ❑ ❑ f,0.001- f,00.000 ACQUIRED DISPOSE ® f100.001- f,.000.000 had received the $12,000 ❑ o.e. s,.00D.DDo from two or more tenants, the NATURE OFIMERESi m ownemnlP /oeea or TmN ❑ E..emeM tenants' names would not be ❑ Le.eeMM ... required as long as no single IF RENTAL PROPERTY. GROSS INCOME RECEIVED tenant $10,000 or more. ❑ f0 - 6.99 ❑ SS00 - 61.000 ❑ 61,001 - 6,0.000 paid ® slo.00, - sloo.000 ❑ ovER f,00.000 A married couple would be SOURCES Of RENTAL considered a single tenant. INCOME: II you own a 10% or 0mebr I�emL I.1 Ne nsme al aeM larunl Nel IF • elnple eoume of cane of f10.00 w mom. " ❑NaM Henry Wells NAME OF LENDER' Sophia Petroillo ADDRESS (SUSMr A, —M AoxMWM) 2121 Blue Sky Parkway, Sacramento BUSINESS ACTIVOY, IF ANY. OF LENDER Restaurant Owner INTEREST RATE TERM ( —Yeem) 8 % ❑NDKE IS Years HIGHEST BALANCE DURING REPORTING PERIOD ❑ $500 - $1,000 11 11.001 - 1,OA00 ® $,0.00, - $100.000 ❑ OVER $100.000 ❑ Guemnbr, II eePllaeNle FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions —11 SCHEDULE B Interests in Real Property **AO (Including Rental Income) ► ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS CITY FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 -/-1 14 ---J--J-14 ❑ $100,001 - $1,000,000 ACQUIRED DISPOSED ❑ Over $1,000,000 NATURE OF INTEREST ❑ Ownership /Deed of Trust ❑ Easement ❑ Leasehold ❑ Yrs. remaining Other IF RENTAL PROPERTY, GROSS INCOME RECEIVED ❑ $0 - $499 ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 SOURCES OF RENTAL INCOME: If you own a 10% or greater interest, list the name of each tenant that is a single source of income of $10,000 or more. ❑ None ► ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS CITY FAIR MARKET VALUE IF APPLICABLE, LIST DATE: ❑ $2,000 - $10,000 ❑ $10,001 - $100,000 /14 __j__j 14 ❑ $100,001 - $1,000,000 ACQUIRED DISPOSED ❑ Over $1,000,000 NATURE OF INTEREST ❑ Ownership /Deed of Trust ❑ Easement ❑ Leasehold ❑ Yrs. remaining Other IF RENTAL PROPERTY, GROSS INCOME RECEIVED ❑ $0 - $499 ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 SOURCES OF RENTAL INCOME: If you own a 10% or greater interest, list the name of each tenant that is a single source of income of $10,000 or more. ❑ None * You are not required to report loans from commercial lending institutions made in the lender's regular course of business on terms available to members of the public without regard to your official status. Personal loans and loans received not in a lender's regular course of business must be disclosed as follows: NAME OF LENDER* ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF LENDER INTEREST RATE % ❑ None TERM (Months/Years) HIGHEST BALANCE DURING REPORTING PERIOD ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 ❑ Guarantor, if applicable Comments: NAME OF LENDER' ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF LENDER INTEREST RATE TERM (Months/Years) % ❑ None HIGHEST BALANCE DURING REPORTING PERIOD ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 ❑ Guarantor, if applicable FPPC Form 700 (2014/2015) Sch. B FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866 /275 -3772 www.fppc.ca.gov Instructions — Schedule C Income, Loans, & Business Positions (Income Other Than Gifts and Travel Payments) 'Reporting Income: Report the source and amount of gross income of $500 or more you received during the reporting period. Gross income is the total amount of income before deducting expenses, losses, or taxes and includes loans other than loans from a commercial lending institution. See Reference Pamphlet, page 11. You must also report the source of income to your spouse or registered domestic partner if your community property share was $500 or more during the reporting period. A source of income must be reported only if the source is located in, doing business in, planning to do business in, or has done business during the previous two years in your agency's jurisdiction. See Reference Pamphlet, page 13, for more information about doing business in the jurisdiction. Reportable sources of income may be further limited by your disclosure category located in your agency's conflict of interest code. Reporting Business Positions: You must report your job title with each reportable business entity even if you received no income during the reporting period. Use the comments section to indicate that no income was received. Commonly reportable income and loans include: • Salary/wages, per diem, and reimbursement for expenses including travel payments provided by your employer • Community property interest (50 %) in your spouse's or registered domestic partner's income - report the employer's name and all other required information • Income from investment interests, such as partnerships, reported on Schedule A -1 • Commission income not required to be reported on Schedule A -2 (See Reference Pamphlet, page 8.) • Gross income from any sale, including the sale of a house or car (Report your pro rata share of the total sale price.) • Rental income not required to be reported on Schedule B • Prizes or awards not disclosed as gifts • Payments received on loans you made to others, including loan repayments from a campaign committee (including a candidate's own campaign committee) • An honorarium received prior to becoming a public official (See Reference Pamphlet, page 10, concerning your ability to receive future honoraria.) • Incentive compensation (See Reference Pamphlet, page 12.) Reminders • Code filers — your disclosure categories may not require disclosure of all sources of income. • Do not disclose on Schedule C income, loans, or business positions already reported on Schedules A -2 or B. You are not required to report: • Salary, reimbursement for expenses or per diem, or social security, disability, or other similar benefit payments received by you or your spouse or registered domestic partner from a federal, state, or local government agency. • Stock dividends and income from the sale of stock unless the source can be identified. • Income from a PIERS retirement account. See Reference Pamphlet, page 11, for more exceptions to income reporting. To Complete Schedule C: Part 1. Income Received /Business Position Disclosure • Disclose the name and address of each source of income or each business entity with which you held a business position. • Provide a general description of the business activity if the source is a business entity. • Check the box indicating the amount of gross income received. • Identify the consideration for which the income was received. • For income from commission sales, check the box indicating the gross income received and list the name of each source of commission income of $10,000 or more. See Reference Pamphlet, page 8. Note: If you receive commission income on a regular basis or have an ownership interest of 10% or more, you must disclose the business entity and the income on Schedule A -2. • Disclose the job title or business position, if any, that you held with the business entity, even if you did not receive income during the reporting period. Part 2. Loans Received or Outstanding During the Reporting Period • Provide the name and address of the lender. • Provide a general description of the business activity if the lender is a business entity. • Check the box indicating the highest balance of the loan during the reporting period. • Disclose the interest rate and the term of the loan. For variable interest rate loans, disclose the conditions of the loan (e.g., Prime + 2) or the average interest rate paid during the reporting period. The term of the loan is the total number of months or years given for repayment of the loan at the time the loan was entered into. • Identify the security, if any, for the loan. FPPC Form 700 (2014/2015) FPPC Advice Email: advice@fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions —13 SCHEDULE C Income, Loans, & Business Positions (Other than Gifts and Travel Payments) NAME OF SOURCE OF INCOME ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE YOUR BUSINESS POSITION GROSS INCOME RECEIVED ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 CONSIDERATION FOR WHICH INCOME WAS RECEIVED ❑ Salary ❑ Spouse's or registered domestic partner's income (For self - employed use Schedule A -2.) ❑ Partnership (Less than 10% ownership. For 10% or greater use Schedule A -2.) M Sala of (Real property, car, boat, etc.) ❑ Loan repayment Iry ❑ Commission or ❑ Rental Income, list each source of $10,000 or more (Describe) ❑ Other (Describe) NAME OF SOURCE OF INCOME ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE YOUR BUSINESS POSITION GROSS INCOME RECEIVED ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ $10,001 - $100,000 ❑ OVER $100,000 CONSIDERATION FOR WHICH INCOME WAS RECEIVED ❑ Salary ❑ Spouse's or registered domestic partner's income (For self - employed use Schedule A -2.) ❑ Partnership (Less than 10% ownership. For 10% or greater use Schedule A -2.) ❑ Sale of (Real property, car, boat, etc.) ❑ Loan repayment ❑ Commission or ❑ Rental Income, list each source of $10,000 or more ❑ Other (Describe) (Describe) * You are not required to report loans from commercial lending institutions, or any indebtedness created as part of a retail installment or credit card transaction, made in the lender's regular course of business on terms available to members of the public without regard to your official status. Personal loans and loans received not in a lender's regular course of business must be disclosed as follows: NAME OF LENDER" INTEREST RATE TERM (Months/Years) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF LENDER ❑ None SECURITY FOR LOAN ❑ None ❑ Personal residence F-1 Real ProDerty HIGHEST BALANCE DURING REPORTING PERIOD ❑ $500 - $1,000 ❑ $1,001 - $10,000 ❑ Guarantor ❑ $10,001 - $100,000 ❑ OVER $100,000 ❑ Other — Comments: Street address city (Describe) FPPC Form 700 (2014/2015) Sch. C FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — Schedule D Income — Gifts 4 gift is anything of value for which you have not provided 'rrraqual or greater consideration to the donor. A gift is reportable if its fair market value is $50 or more. In addition, multiple gifts totaling $50 or more received during the reporting period from a single source must be reported. It is the acceptance of a gift, not the ultimate use to which it is put, that imposes your reporting obligation. Except as noted below, you must report a gift even if you never used it or if you gave it away to another person. If the exact amount of a gift is unknown, you must make a good faith estimate of the item's fair market value. Listing the value of a gift as "over $50" or "value unknown" is not adequate disclosure. In addition, if you received a gift through an intermediary, you must disclose the name, address, and business activity of both the donor and the intermediary. You may indicate an intermediary either in the "source" field after the name or in the "comments" section at the bottom of Schedule D. Commonly reportable gifts include: • Tickets /passes to sporting or entertainment events • Tickets /passes to amusement parks • Parking passes not used for official agency business • Food, beverages, and accommodations, including those provided in direct connection with your attendance at a convention, conference, meeting, social event, meal, or like gathering • Rebates /discounts not made in the regular course of business to members of the public without regard to official status • Wedding gifts (See Reference Pamphlet, page 16) • An honorarium received prior to assuming office (You may report an honorarium as income on Schedule C, rather than as a gift on Schedule D, if you provided services of equal or greater value than the payment received. See Reference Pamphlet, page 10, regarding your ability to receive future honoraria.) • Transportation and lodging (See Schedule E.) • Forgiveness of a loan received by you You are n9t required to disclose: • Gifts that were not used and that, within 30 days after receipt, were returned to the donor or delivered to a charitable organization or government agency without Reminders • Gifts from a single source are subject to a $440 limit during 2014. See Reference Pamphlet, page 10. • Code filers — you only need to report gifts from reportable sources. Gift Tracking Mobile Application • FPPC has created a gift tracking app for mobile devi that helps filers track gifts and provides a quick and easy way to upload the information to the Form 700. Visit FPPC's website to download the app. being claimed by you as a charitable contribution for tax purposes • Gifts from your spouse or registered domestic partner, child, parent, grandparent, grandchild, brother, sister, and certain other famly members (See Regulation 18942 for a complete list.). The exception does not apply if the donor was acting as an agent or intermediary for a reportable source who was the true donor. • Gifts of similar value exchanged between you and an individual, other than a lobbyist registered to lobby your state agency, on holidays, birthdays, or similar occasions • Gifts of informational material provided to assist you in the performance of your official duties (e.g., books, pamphlets, reports, calendars, periodicals, or educational seminars) • A monetary bequest or inheritance (However, inherited investments or real property may be reportable on other schedules.) • Personalized plaques or trophies with an individual value of less than $250 • Campaign contributions • Up to two tickets, for your own use, to attend a fundraiser for a campaign committee or candidate, or to a fundraiser for an organization exempt from taxation under Section 501(c)(3) of the Internal Revenue Code. The ticket must be received from the organization or committee holding the fundraiser. • Gifts given to members of your immediate family if the source has an established relationship with the family member and there is no evidence to suggest the donor had a purpose to influence you. (See Regulation 18943.) • Free admission, food, and nominal items (such as a pen, pencil, mouse pad, note pad or similar item) available to all attendees, at the event at which the official makes a speech (as defined in Regulation 18950(b)(2)), so long as the admission is provided by the person who organizes the event. • Any other payment not identified above, that would otherwise meet the definition of gift, where the payment is made by an individual who is not a lobbyist registered to lobby the official's state agency, where it is clear that the gift was made because of an existing personal or business relationship unrelated to the official's position and there is no evidence whatsoever at the time the gift is made to suggest the donor had a purpose to influence you. To Complete Schedule D: • Disclose the full name (not an acronym), address, and, if a business entity, the business activity of the source. • Provide the date (month, day, and year) of receipt, and disclose the fair market value and description of the gift. FPPC Form 700 (2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions —15 cm SCHEDULE D Income — Gifts ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) Comments: Name ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mm /dd /yy) VALUE DESCRIPTION OF GIFT(S) FPPC Form 700 (2024/2015) Sch. D FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions — Schedule E Travel Payments, Advances, and Reimbursements Travel payments reportable on Schedule E include advances and reimbursements for travel and related expenses, including lodging and meals. Gifts of travel may be subject to the gift limit. In addition, certain travel payments are reportable gifts, but are not subject to the gift limit. To avoid possible misinterpretation or the perception that you have received a gift in excess of the gift limit, you may wish to provide a specific description of the purpose of your travel. See the FPPC fact sheet entitled "Limitations and Restrictions on Gifts, Honoraria, Travel, and Loans" at www.fppc.ca.gov. You are = required to disclose: • Travel payments received from any state, local, or federal government agency for which you provided services equal or greater in value than the payments received, such as reimbursement for travel on agency business from your government agency employer. • A payment for travel from another local, state, or federal government agency and related per diem expenses when the travel is for education, training or other inter - agency programs or purposes. • Travel payments received from your employer in the normal course of your employment that are included in the income reported on Schedule C • A travel payment that was received from a non -profit entity exempt from taxation under Internal Revenue Code Section 501(c)(3) for which you provided equal or greater consideration, such as reimbursement for travel on business for a 501(c)(3) organization for which you are a board member. Note: Effective January, 2014, certain travel payments may not be reportable if reported on Form 801 by your agency. To Complete Schedule E: • Disclose the full name (not an acronym) and address of the source of the travel payment. • Identify the business activity if the source is a business entity. • Check the box to identify the payment as a gift or income, report the amount, and disclose the date(s). - Travel payments are gifts if you did not provide services that were equal to or greater in value than the payments received. You must disclose gifts totaling $50 or more from a single source during the period covered by the statement. When reporting travel payments that are gifts, you must provide a description of the gift and the date(s) received. Travel payments are income if you provided services that were equal to or greater in value than the payments received. You must disclose income totaling $500 or more from a single source during the period covered by the statement. You have the burden of proving the payments are income rather than gifts. When reporting travel payments as income, you must describe the services you provided in exchange for the payment. You are not required to disclose the date(s) for travel payments that are income. Example: City council member Rick Chandler is the chairman of a 501 (c)(6) trade association and the association pays for Rick's travel to attend its meetings. Because Rick is deemed to be providing equal or greater consideration for the travel payment by virtue of serving on the board, this payment may be reported as income. Payments for Rick to attend other events for which Rick is not providing services are likely considered gifts. ► NAME OF SOURCE Health Services Trade Association ADDRESS(Buein Add— Aocepleele) 1230 K Street, Ste. 610 CITY AND STATE Sacramento, CA BUSINESS ACTIVITY IF ANY. OF SOURCE E3 501 (W) Association of Healthcare Workers DATE($) __J —1_ - — _/_ AMT. S 688.00 m �rwn�c�l TYPE OF PAYMENT (must Check one) ❑ Gift ® Income DESCRIPTION Travel reimbursement_ for board. meeting FPPC Form 700(2014/2015) FPPC Advice Email: advice @fppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov Instructions -17 Owl SCHEDULE E Income — Gifts Travel Payments, Advances, and Reimbursements • Mark either the gift or income box. • Mark the "501(c)(3)" box for a travel payment received from a nonprofit 501(c)(3) organization or the "Speech" box if you made a speech or participated in a panel. These payments are not subject to the $440 gift limit, but may result in a disqualifying conflict of interest. ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE ❑ 501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE(S): __J-/_ - AMT: $ (If gift) TYPE OF PAYMENT: (must check one) ❑ Gift ❑ Income ❑ Made a Speech /Participated in a Panel ❑ Other - Provide Description ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE ❑ 501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE(S): _ /_ /_ - ___J__J- AMT: $ (If gift) TYPE OF PAYMENT: (must check one) ❑ Gift ❑ Income ❑ Made a Speech /Participated in a Panel ❑ Other - Provide Description ,%w Comments: ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE ❑ 501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE(S): AMT: $ (If gift) TYPE OF PAYMENT: (must check one) ❑ Gift ❑ Income ❑ Made a Speech /Participated in a Panel ❑ Other - Provide Description ► NAME OF SOURCE (Not an Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE ❑ 501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE(S): AMT: $ (If gift) TYPE OF PAYMENT: (must check one) ❑ Gift ❑ Income ❑ Made a Speech /Participated in a Panel ❑ Other - Provide Description FPPC Form 700 (2014/2015) Sch. E FPPC Advice Email: advice &ppc.ca.gov FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov