Fillable Conflictofinterest (California State University, Fresno)

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Conflictofinterest (California State University, Fresno)

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STATEMENT OF ECONOMIC INTERESTS
FOR
PRINCIPAL INVESTIGATORS
NAME (LAST) (FIRST) (MIDDLE)
ACADEMIC UNIT OR DEPARTMENT MAIL CODE
( )
TELEPHONE NUMBER
FPPC Form 700-U (2002/2003)
FPPC Toll-Free Helpline: 866/ASK-FPPC
Name of Entity:
Address of Entity:
Principal Business of Entity:
Amount of Funding: $
Estimated
Actual
3. Filer Information
1. Information Regarding Funding Entity:
(Use a separate Form 700-U for each funding entity.)
3. Filer Information - Cont.
E-MAIL ADDRESS
Date Received
Campus Use Only
Please type or print in ink
700-U
FAIR POLITICAL PRACTICES COMMISSION
CALIFORNIA
FORM
2. Type of Statement (Check at least one box)
Initial (for new or renewal funding)
Date of Funding: / /
Completion Statement
The research project expired on: / /
E. Have you received gifts from the entity listed in Part 1
within the last 12 months valued at $50 or more?
No
Yes
– describe below..
Description of Gift:
Value: $
Date Received: / /
D. Have you received loans from the entity in Part 1 for
which the balance exceeds $500 in the past 12 months?
No
Yes
– balance is:
$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
Exceeds $100,000
If you checked “yes,” was the loan:
Secured
Unsecured Interest rate: %
Was the loan entirely repaid within the last 12 months?
No
Yes
Campus:
ID No:
A. Are you a director, officer, partner, trustee, consultant,
employee, or do you hold a position of management in
the entity listed in Part 1? No
Yes
Title:
B. Do you, your spouse, or your dependent children have
an investment of $2,000 or more in the entity listed in
Part 1 above? No
Yes
– value is:
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Exceeds $1,000,000
If you have sold or divested yourself of investments:
Date Divested: / /
Description:
Amt:$ date(s):
/ / / /
(If applicable)
Type of Payment: (check one)
Gift Income
F. Has the entity in Part 1 paid you for your travel?
No
Yes
– describe below..
4. Verification
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)
Signature
(File the originally signed statement with your university.)
The Form 700-U is for university use only.
This statement is a public record under Gov. Code section 81008(a).
TITLE OF RESEARCH PROJECT
C. Have you received income of $500 or more from the
entity listed in Part 1 within the last 12 months?
No
Yes
– amount is:
$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
Exceeds $100,000
Was income received through your spouse?
No
Yes
Clear Form
Print Form
FPPC Form 700-U (2002/2003)
FPPC Toll-Free Helpline: 866/ASK-FPPC
Who Files Form 700-U?
This form must be filed by all persons employed by UC
or CSU who have principal responsibility for a research
project if the project is to be funded or supported, in
whole or in part, by a contract or grant (or other funds
earmarked by the donor for a specific research project
or for a specific researcher) from a nongovernmental
entity.
Research funding by certain nonprofit entities will not
trigger disclosure on the Form 700-U. For a list of these
exempt nonprofits, refer to http://www.ucop.edu/
research/exempt.html.
What is an Investment?
“Investment” means any financial interest in a business
entity in which you, your spouse, or your dependent
children have a direct, indirect, or beneficial interest
totaling $2,000 or more. Reportable investments
include, stocks, bonds, warrants, and options, including
those held in margin or brokerage accounts. (See Gov.
Code section 82034.)
What is Income?
“Income” means a payment received, including but not
limited to any salary, wage, advance, dividend, interest,
rent, proceeds from any sale, gift, including any gift of
food or beverage, loan forgiveness or payment of
indebtedness received by the filer, reimbursement for
expenses, per diem, or contribution to an insurance or
pension program paid by any person other than an
employer, and any community property interest in
income of a spouse. Income also includes an
outstanding loan. Income of an individual also includes
a pro rata share of any income of any business entity or
trust in which the individual or spouse owns directly,
indirectly, or beneficially, a 10% interest or greater.
Income includes your gross income and your community
property interest in your spouse’s gross income totaling
$500 or more. Gross income is the total amount of
income before deducting expenses, losses, or taxes.
(See Gov. Code section 82030.)
What is a Loan?
Loans received or outstanding are reportable if they total
$500 or more from a single lender. Your community
property interest in loans received by your spouse also
must be reported. (See Gov. Code section 82030(a).)
What is a Gift?
“Gift” means anything of value, for which you have not
provided equal 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
from a reportable 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.
Therefore 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 not known, 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.
Commonly reportable gifts include:
• Tickets/passes to sporting or entertainment events.
• Tickets/passes to amusement parks.
• Parking passes.
• Food, beverages, and accommodations, including
that provided in direct connection with your
attendance at a convention, conference, meeting,
social event, meal, or like gathering, where you did
not give a speech, participate in a panel or seminar,
or provide a similar service.
• Rebates/discounts not made in the regular course of
business to members of the public without regard to
official status.
• Wedding gifts.
• An honorarium. You may report an honorarium as
income rather than as a gift if you provided services
of equal or greater value than the payment received.
• Transportation and lodging
• Forgiveness of a loan received by you.
(See Gov. Code section 82028.)
Instructions for Completing
Form 700-U
700-U
CALIFORNIA
FORM
What is a Travel Payment?
Travel payments include advances and
reimbursements for travel and related expenses,
including lodging and meals.
• Travel payments are gifts if you did not provide
services which 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. Gifts
of travel are reportable without regard to where the
donor is located.
When reporting travel payments which are gifts, you
must provide a description of the gift and the
date(s) received.
• Travel payments are income if you provided
services which 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. The
filer has 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 which are
income.
Gifts of travel may be subject to a $340 gift limit. In
addition, certain travel payments are reportable gifts,
but are not subject to the gift limit. See the FPPC
fact sheet entitled Limitations and Restrictions on
Gifts, Honoraria, Travel, and Loans (1/2003), which
can be obtained from the FPPC at www.fppc.ca.gov.
You are not 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.
• Travel payments received from your employer in the
normal course of your employment.
Instructions for Completing
Form 700-U (continued)
700-U
CALIFORNIA
FORM
FPPC Form 700-U (2002/2003)
FPPC Toll-Free Helpline: 866/ASK-FPPC
• Payments or reimbursements for transportation
within California in connection with an event at
which you gave a speech, participated in a panel or
seminar, or performed a similar service.
• Food, beverages, and necessary accommodations
received directly in connection with an event held
inside or outside California at which you gave a
speech, participated in a panel, or provided a
similar service. Note that payments for
transportation outside of California are reportable.
• A travel payment which was received from a
nonprofit entity exempt from taxation under IRS
Code section 501(c)(3) for which you provided
equal or greater consideration.
Check the box to indicate if the payment was a gift or
income, report the amount, and disclose the date(s) if
applicable.
Violations
Failure to file the required Statement of Economic
Interests or failure to report a financial interest may
subject a principal investigator to civil liability, including
fines, as well as University discipline. (Government
Code sections 81000-91014)
If you need more information, contact the FPPC.
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Completed 20 July 2020

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