December 2016
2016/2017
Statement of
Economic Interests
Form 700
California Fair Political Practices Commission
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
A Public Document
Also available on the FPPC website:
Form700inExcelformat
Reference Pamphlet for Form 700
What’s New
Gift Limit Increase
The gift limit increased to $470 for calendar years 2017
and 2018. The gift limit during 2016 was $460.
Gifts of Travel
If an individual receives a payment that is a reportable
gift for travel taken on or after January 1, 2016, he or she
must disclose the travel destination. (See Schedule E
instructions for other details that must be disclosed.)
Who must le:
• Electedandappointedofcialsandcandidateslistedin
Government Code Section 87200
• Employees,appointedofcials,andconsultantsling
pursuanttoaconictofinterestcode(“codelers”).
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ofcesthatare
designatedinaconictofinterestcode(e.g.,county
sheriffs, city clerks, school board trustees, and water
board members)
Exception: Candidates for a county central committee are
notrequiredtoletheForm700.
• Members of newly created boards and commissions not
yetcoveredunderaconictofinterestcode
• Employees in newly created positions of existing
agencies
See Reference Pamphlet, page 3, at www.fppc.ca.gov.
Where to le:
87200 Filers
Stateofces  Your agency
Judicialofces  The clerk of your court
Retired Judges  Directly with FPPC
Countyofces  Yourcountylingofcial
Cityofces  Your city clerk
Multi-Countyofces  Your agency
Code Filers — State and Local Ofcials, Employees,
and Consultants Designated in a Conict of Interest
Code: File with your agency, board, or commission unless
otherwisespeciedinyouragency’scode(e.g.,Legislative
staffles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ofce.
How to le:
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byyourlingofcertoleelectronically
under Government Code Section 87500.2. Instructions,
examples, FAQs, and a reference pamphlet are available
to help answer your questions.
When to le:
Annual Statements
March 1, 2017
- ElectedStateOfcers
- Judges and Court Commissioners
- State Board and State Commission Members listed
in Government Code Section 87200
April 3, 2017
- Mostotherlers
Individualslingunderconictofinterestcodesincityand
countyjurisdictionsshouldverifytheannuallingdatewith
theirlocallingofcers.
Statementspostmarkedbythelingdeadlineare
consideredledontime.
Assuming Ofce and Leaving Ofce Statements
Mostlerslewithin30daysofassumingorleavingofce
or within 30 days of the effective date of a newly adopted
oramendedconictofinterestcode.
Exception:
IfyouassumedofcebetweenOctober1, 2016, and
December 31, 2016,andledanassumingofcestatement,
youarenotrequiredtoleanannualstatementuntilMarch
1, 2018, or April 2, 2018, whichever is applicable. The
annualstatementwillcoverthedayafteryouassumedofce
through December 31, 2017. See Reference Pamphlet,
pages 6 and 7, for additional exceptions.
Candidate Statements
Filenolaterthanthenalling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ledform.Obtain
amendment schedules at www.fppc.ca.gov.
There is no provision for ling deadline extensions
unless the ler is serving in active military duty.
Statements of 30 pages or less may be faxed by the
deadline as long as the originally signed paper version is
sentbyrstclassmailtothelingofcialwithin24hours.
Introduction
The Political Reform Act (Gov. Code Sections 81000-

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




and candidates are subject to a limit. During 2015 and
2016, the gift limit was $460 from a single source per
calendar year. For years 2017-2018, the limit increased to
$470 from a single source during a calendar year.

state employees are subject to a $10 limit per calendar

with the Secretary of State. See Reference Pamphlet,
page 10.

their agency to determine if other restrictions apply.


to disqualify themselves from making, participating in, or

affect their economic interests. This may include interests
they are not required to disclose (i.e., a personal residence


city councilmembers, members of boards of supervisors,

publicly identify the economic interest that creates a

or vote takes place at a public meeting. For more
information, consult Government Code Section 87105,

www.fppc.ca.gov.
Honorarium Ban

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

on loans. See Reference Pamphlet, page 14.

There are restrictions on representing clients or employers
before former agencies. The provisions apply to elected


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





circumstances.


cases, to the Attorney General or district attorney) for


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.
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Introducon




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.
 
from persons seeking access.
 Reproduction fees of no more than 10 cents per
page may be charged.
Types of Form 700 Filings


in a position designated, or that will be designated, in




you were sworn in.
 


(including loans, gifts, and travel payments) received
during the 12 months prior to the date you assumed the


or the Commission on Judicial Performance, your

nominated to the position.

Maria Lopez was nominated by the Governor to serve
on a state agency board that is subject to state Senate

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
loans, gifts, and travel payments) received during the 12
months prior to that date.


the effective date of the code or amendment, whichever is
applicable.
 
positions held on the effective date of the code or

(including loans, gifts, and travel payments) received
during the 12 months prior to the effective date of the
code or amendment is reportable.

Generally, the period covered is January 1, 2016,
through December 31, 2016
the statement is different than January 1, 2016, through
December 31, 2016
between October 1, 2015, and December 31, 2015 or you
are combining statements), you must specify the period
covered.
 
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 2016.
 
period, disclose under the old category until the

and disclose under the new disclosure category through
the end of the reporting period.

Generally, the period covered is January 1, 2016,
through the date you stopped performing the duties of

1, 2016, through the date you stopped performing the

between October 1, 2015, and December 31, 2015, or
you are combining statements), the period covered must

calendar years.
 
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 2016.



in real property, and business positions held on the date


payments) received during the 12 months prior to the date

change the preprinted dates on Schedules A-1, A-2, and B.
Candidates running for local elective county
sheriffs, city clerks, school board trustees, or water


position. The code may be obtained from the agency of
the elected position.


an amendment as soon as possible. You are only required
to amend the schedule that needs to be revised; it is not

schedules from the FPPC website at www.fppc.ca.gov.
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Types of Statements
Instructions

Enter your name, mailing address, and daytime telephone
number in the spaces provided. Because the Form 700 is
a public document, 


 
or court. Consultants must enter the public agency name


Department of Finance; Hope County Superior Court)
 
applicable. (Examples: Division of Waste Management;
Board of Accountancy; District 45). 
 Enter your position title. (Examples: Director; Chief
Counsel; City Council Member; Staff Services Analyst)
 
who also is a member of a county board or commission),


expanded statement.
 To do this, enter the name of the other agency(ies) with

the space provided.  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

with each agency.

you must complete a separate statement. For example, a
city council member who assumes a position with a county



include both positions.

Scott Baker is a city council member for the City of Lincoln

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




 Check the box indicating the jurisdiction of your agency
and, if applicable, identify the jurisdiction. Judges, judicial
candidates, and court commissioners have statewide

Pamphlet, page 13, to determine their jurisdiction.
 
which your agency has jurisdiction.
 


county or city in which the agency has jurisdiction.


in portions of Yuba and Sutter Counties.

Check at least one box. The period covered by a statement

are completing a 2016 annual statement, do not change the
2017. Your annual statement is
used for reporting the previous years economic interests.
January 1,
2017, through December 31, 2017, will be disclosed on your
2018. See Reference Pamphlet, page 4.
Combining Statements: Certain types of statements may be




FPPC.

 Complete the Schedule Summary after you have reviewed
each schedule to determine if you have reportable
interests.
 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

Please do not attach any blank schedules.


entering the date signed. All statements must have an original



available to help answer your questions. When you sign
your statement, you are stating, under penalty of perjury,



FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 1
State
Judge or Court Commissioner (Statewide Jurisdiction)
Multi-County
County of
City of
Other
  (Check at least one box)
Agency Name (Do not use acronyms)
Division, Board, Department, District, if applicable Your Position

If ling for multiple positions, list below or on an attachment. (Do not use acronyms)
Agency:
Position:
x
Yuba & Sutter Counties
Board MemberN/A
N/A
Feather River Irrigation District
 Date Left / /
(Check one)
The period covered is January 1, 2016, through the date of
leaving ofce.
The period covered is / / , through
the date of leaving ofce.
 The period covered is January 1, 2016, through
December 31, 2016.
The period covered is / / , through
December 31, 2016.


FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
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.
    

(month, day, year)
 (Check at least one box)
State
Judge or Court Commissioner (Statewide Jurisdiction)
Multi-County
County of
City of
Other
 (Check at least one box)
 Election year and ofce sought, if different than Part 1:
 Date assumed / /
 
Ofcial Use Only
Please type or print in ink.
700
  
CALIFORNIA FORM
Agency Name (Do not use acronyms)
Division, Board, Department, District, if applicable Your Position

   
MAILING ADDRESS STREET CITY STATE ZIP CODE
( )
DAYTIME TELEPHONE NUMBER
E-MAIL ADDRESS
(Business or Agency Address Recommended - Public Document)

(File the originally signed statement with your ling ofcial.)


If ling for multiple positions, list below or on an attachment. (Do not use acronyms)
Agency:
Position:
-or-
-or-
None - No reportable interests on any schedule
 
Schedules attached
 Investments – schedule attached
 Investments – schedule attached
 Real Property – schedule attached
Total number of pages including this cover page:
-or-
 Income, Loans, & Business Positions – schedule attached
 Income Gifts – schedule attached
 Income Gifts Travel Payments – schedule attached
Clear Page
Print

FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons - 3
Common Reportable Interests
Schedule A-1 Stocks, 
Schedule A-2 Business entities (including certain independent contracting), sole proprietorships,
partnerships, LLCs, corporations, and trusts
Schedule B Rental property in the jurisdiction, or within two miles of the boundaries of the
jurisdiction
Schedule C Non-governmental
Schedule D Gifts from businesses (such as tickets to sporting or entertainment events)
Schedule E Travel payments from third parties (not your employer)

Schedule A-1 

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

9 NoSchedule Summary on the Cover Page
 Make sure you

9 The Form 700 is a public document.
9 Most individuals must consult their

9 agencies.
Questions and Answers
General
Q. What is the reporting period for disclosing interests

statement?
 
reportable investments, interests in real property, and
business positions held on the date you assumed

loans, gifts and travel payments) received during the 12

On a candidate statement, disclose all reportable
investments, interests in real property, and business

candidacy. You must also disclose income (including
loans, gifts and travel payments) received during the

candidacy.


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

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.


 


they are or may be performing the duties of the
position.



 
statement for the new agency.



property?
 
economic interests until such time as dissolution of

property agreement has been reached prior to that

be reported. Contact the FPPC for more information.
Investment Disclosure



company?
 


Reference Pamphlet, page 13.

rental property in my jurisdiction, our primary residence,

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

with the SEC are not reportable.

that contains stocks through an account managed by


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.
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 4
Questions and Answers
Continued




an agreement with a large insurance company. My
contract does not have resale value because of its

the fair market value for my business on Schedule A-2
of the Form 700?
A. Yes. Even if there are no tangible assets, intangible
assets, such as relationships with companies and


purposes, such as marital dissolutions or estate



goodwill that generates income are not without a
determinable value. The Form 700 does not require a
precise fair market value; it is only necessary to check
a box indicating the broad range within which the value
falls.





 

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.

$2,000 - $10,000. Late last year the value of this stock
fell below and remains at less than $2,000. How should

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

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

 
(e.g., common stock valued at $2,000 or more), those
interests are reportable (not the actual Section 529

then nothing is reported.
Income Disclosure


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 located in or doing business on a
regular basis in your jurisdiction must be disclosed.

clients from whom my pro rata share of income is
$10,000 or more on Schedule A-2 because of their right

names?
A. Regulation 18740 provides a procedure for requesting

disclosed if disclosure of the name would violate a
legally recognized privilege under California or Federal
law. This regulation may be obtained from our website
at www.fppc.ca.gov. See Reference Pamphlet, page
14.

reportable based on my limited disclosure category.
However, some of the sources of income to my law

disclose this income?
A. Yes, even though the law practice is not reportable,
reportable sources of income to the law practice of
$10,000 or more must be disclosed. This information
would be disclosed on Schedule C with a note in the

is not a reportable investment. The note would be for
informational purposes only; it is not a requirement.
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 5
Questions and Answers
Continued

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


all of his business is based on his own billings and

community property interest in this business and the
income generated in this manner?
 
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


reported.


A. Report the name of the employer as a source of income
on Schedule C.

sources of income on Schedule A-2, Part 3, are the
patients or their insurance carriers considered sources
of income?
 
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.


A. No. Loans received from family members are not
reportable.


report this loan repayment on my Form 700?
A. No. Payments received on a loan made to a family
member are not reportable.
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 6

Q. During this reporting period we switched our principal




date?
 
because you previously owned the property. However,

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.


need to report this property interest?
A. Yes. You are required to report this property because
it is located within 2 miles of the boundaries of the city
you manage.

for my daughter?
A. You are not required to disclose a home used as a
personal residence for a family member unless you
receive income from it, such as rental income.



property on my Form 700?
A. No. Simply being a co-signer on a loan for property
does not create a reportable interest in real property for
you.
Gift Disclosure

valued at $100 each, but gave the tickets to a friend

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.
Q. Mary and Joe Benson, a married couple, want to give a

considered a separate source for purposes of the gift
limit and disclosure?
A. Yes, each spouse may make a gift valued at the gift
limit during a calendar year. For example, during 2016
the gift limit was $460, so the Bensons may have given
the supervisor artwork valued at no more than $920.
The supervisor must identify Joe and Mary Benson as
the sources of the gift.



basket valued at $120. The gift basket was donated by
Doug Brewer, a citizen in our city. At the same event,

$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.
Q. 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

reportable source of income under the code.


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.



considered informational material?
 
attendance at a concert, or sporting event, are gifts
subject to reporting and limits.
Questions and Answers
Continued
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 7

Investments

entity (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

you, your spouse or registered domestic partner, or your

totaling $2,000 or more at any time during the reporting
period. See Reference Pamphlet, page 13.

 Stocks, bonds, warrants, and options, including those held
in margin or brokerage accounts and managed investment
funds (See Reference Pamphlet, page 13.)
 Sole proprietorships
 


 
investments even if they are legally separate property
 
 
retirement account (See Reference Pamphlet, page 15.)
 
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

 G

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

 
 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.)
 
CalPERS and CalSTRS plans)
 Certain interests held in a blind trust (See Reference
Pamphlet, page 16.)
 to report ownership of less than 10%

the investment is not a stock or corporate bond. See second
example below.
 to report ownership of 10% or greater
(e.g., a sole proprietorship).


 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




 
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.




interest code requires full disclosure of investments. John
must disclose his stock holdings of $2,000 or more in any
company that is located in or 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.
Reminders
• 
• Did you hold investments at any time during the period
covered by this statement?
• 

FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 8

 

 

 

 

 

 
16 16
16
16
1616
16
1616
Name
  
   
  
   
  
   
  
   
  
   
  
   


Investments


Do not attach brokerage or nancial statements.
700
  
CALIFORNIA FORM
FPPC Form 700 (2016/2017) Sch. A-1
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
 
$2,000 - $10,000 $10,001 - $100,000
$100,001 - $1,000,000 Over $1,000,000
 
$2,000 - $10,000 $10,001 - $100,000
$100,001 - $1,000,000 Over $1,000,000
 
$2,000 - $10,000 $10,001 - $100,000
$100,001 - $1,000,000 Over $1,000,000
 
$2,000 - $10,000 $10,001 - $100,000
$100,001 - $1,000,000 Over $1,000,000
 
$2,000 - $10,000 $10,001 - $100,000
$100,001 - $1,000,000 Over $1,000,000
 
$2,000 - $10,000 $10,001 - $100,000
$100,001 - $1,000,000 Over $1,000,000
16
 
Stock Other
(Describe)
Partnership
Received of $0 - $499
   (Report on Schedule C)
 
Stock Other
(Describe)
Partnership
  
   (Report on Schedule C)
 
Stock Other
(Describe)
Partnership
  
   (Report on Schedule C)
 
Stock Other
(Describe)
Partnership
Received of $0 - $499
   (Report on Schedule C)
 
Stock Other
(Describe)
Partnership
Received of $0 - $499
   (Report on Schedule C)
 
Stock Other
(Describe)
Partnership
  
   (Report on Schedule C)
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

FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 10
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 or separately, had a
10% or greater interest, totaling $2,000 or more, during the
reporting period and which is located in, doing business in,
planning to do business in, or which has done business during

Reference Pamphlet, page 13. A trust located outside your

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.

 Disclose the name and address of the business entity


 Provide a general description of the business activity of the
entity.
 Check the box indicating the highest fair market value of
your investment during the reporting period.
 
during the reporting period, enter the date acquired or
disposed.
 
 Disclose the job title or business position you held with the

trustee, employee, or held any position of management). A
business position held by your spouse is not reportable.
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

 income is the total amount of income
before deducting expenses, losses, or taxes.
 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

 Disclose each source of income and outstanding loan
to the business entity or trust
your pro rata share of the gross income (including your


from that source was $10,000 or more during the reporting
period. See Reference Pamphlet, page 11, for examples.

if not considered salary. See Regulation 18232. Loans

regular course of business on terms available to members

reportable.
 Disclose each individual or entity that was a source
of commission income of $10,000 or more during the

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.

sources of income to disclose. Using phrases such as


amendment to your statement. See Reference Pamphlet,
page 14, for details about requesting an exemption from
disclosing privileged information.
 Report any investments or interests in real property
held or leased by the entity or trust
pro rata share of the interest held was $2,000 or more during
the reporting period. Attach additional schedules or use

 Check the applicable box identifying the interest held as
real property or an investment.
 
business entity.
 

 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.)
 
 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.
     
      

 

 

 

 
16 16
16 1616 16

Investments, Income, and Assets
 
  

Name
Address (Business Address Acceptable)
Name
Address (Business Address Acceptable)
 
$0 - $1,999
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
 
$0 - $1,999
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
   
   
 REAL PROPERTY
   or
    
Description of Business Activity or
City or Other Precise Location of Real Property
 REAL PROPERTY
   or
    
Description of Business Activity or
City or Other Precise Location of Real Property
     
 BY  
     
 BY  
Check one
Trust, go to 2 Business Entity, complete the box, then go to 2
Check one
Trust, go to 2 Business Entity, complete the box, then go to 2
     
      
    
  TO  
    
  TO  
Name
700
Check one box: Check one box:


FPPC Form 700 (2016/2017) Sch. A-2
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
$0 - $499
$500 - $1,000
$1,001 - $10,000
$0 - $499
$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
 
$10,001 - $100,000
 
  
CALIFORNIA FORM
 
 
 
  Stock Partnership
Leasehold Other
Check box if additional schedules reporting investments or real property
are attached
Yrs. remaining
 
  Stock Partnership
Leasehold Other
Check box if additional schedules reporting investments or real property
are attached
Yrs. remaining
16 16
Other
 
Partnership Sole Proprietorship
Other
 
Partnership Sole Proprietorship
None
None
or
or
Names listed below
Names listed below
Clear Page
Print
 
gross amount you received.
 
received rental income, list the name of the source(s) if
your pro rata share of the gross income from any single

you received a total of $10,000 or more from two or more
tenants acting in concert (in most cases, this will apply
to married couples), disclose the name of each tenant.

 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
lenders regular course of business on terms available


When reporting a loan:
- Provide the name and address of the lender.
- 
- 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.
- 

real property, report the additional loan(s) on Schedule C.

Joe Nelson is a city planning
commissioner. Joe received
rental income of $12,000
during the reporting period
from a single tenant who
rented property Joe owned

had received the $12,000
from two or more tenants, the

required as long as no single
tenant paid $10,000 or more.
A married couple would be
considered a single tenant.
Instructions – Schedule B

Reminders
• 
not also required to be reported on Schedule C.
• Real property already reported on Schedule A-2, Part 4
is not also required to be reported on Schedule B.
•  do your disclosure categories require
disclosure of real property?
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 12

jurisdiction in which you, your spouse or registered domestic
partner, or your dependent children had a direct, indirect, or

the reporting period. Real property is also considered to be

property or any part of it is located within two miles outside
the boundaries of the jurisdiction or within two miles of any
land owned or used by the local government agency. See
Reference Pamphlet, page 13.

 
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.)
 
real property that are legally held separately by him or her
You are not
 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

report the fair market value of the portion claimed as a tax
deduction.)
 A non-reportable residence can still be

 
Reference Pamphlet, page 16, for exceptions.)

 
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.
 
disclose the number of years remaining on the lease.
NAME OF LENDER
*
ADDRESS (Business Address Acceptable)

 

 

16 1616 16


 
Name
  STREET ADDRESS
  STREET ADDRESS


 
%
None
 

interest, list the name of each tenant that is a single source of
income of $10,000 or more.
 

interest, list the name of each tenant that is a single source of
income of $10,000 or more.
  

Easement
Leasehold
Yrs. remaining
Other
  

Easement
Leasehold
Yrs. remaining
Other

 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000


$500 - $1,000
$0 - $499
$1,001 - $10,000
$10,001 - $100,000


$500 - $1,000
$0 - $499
$1,001 - $10,000
$10,001 - $100,000
  
Guarantor, if applicable

$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
FPPC Form 700 (2016/2017) Sch. B
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
700
 
CALIFORNIA FORM
NAME OF LENDER
*
ADDRESS (Business Address Acceptable)

 
%
None
Guarantor, if applicable
  

$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
*



None
None
Sacramento
Henry Wells
Sophia Petroillo
2121 Blue Sky Parkway, Sacramento
Restaurant Owner
8
15 Years
NAME OF LENDER
*
ADDRESS (Business Address Acceptable)

 

 

16 1616 16


 
Name
  STREET ADDRESS
  STREET ADDRESS
 
 
%
None
 

interest, list the name of each tenant that is a single source of
income of $10,000 or more.
 

interest, list the name of each tenant that is a single source of
income of $10,000 or more.
  

Easement
Leasehold
Yrs. remaining
Other
  

Easement
Leasehold
Yrs. remaining
Other

 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000


$500 - $1,000
$0 - $499
$1,001 - $10,000
$10,001 - $100,000


$500 - $1,000
$0 - $499
$1,001 - $10,000
$10,001 - $100,000
  
Guarantor, if applicable

$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
FPPC Form 700 (2016/2017) Sch. B
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
700
 
CALIFORNIA FORM
NAME OF LENDER
*
ADDRESS (Business Address Acceptable)

 
%
None
Guarantor, if applicable
  

$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
*



None
None
4600 24th Street
Sacramento
Henry Wells
Sophia Petroillo
2121 Blue Sky Parkway, Sacramento
Restaurant Owner
8
15 Years
NAME OF LENDER*
ADDRESS (Business Address Acceptable)
  

 

 
16 1616 16

 

Name
 STREET ADDRESS
 STREET ADDRESS
 
 
% None
   
interest, list the name of each tenant that is a single source of
income of $10,000 or more.
   
interest, list the name of each tenant that is a single source of
income of $10,000 or more.
 
  Easement
Leasehold
Yrs. remaining
Other
 
  Easement
Leasehold
Yrs. remaining
Other

 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
 
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
  
 
$500 - $1,000 $0 - $499 $1,001 - $10,000
$10,001 - $100,000
  
 
$500 - $1,000 $0 - $499 $1,001 - $10,000
$10,001 - $100,000
 
Guarantor, if applicable
 
$500 - $1,000 $1,001 - $10,000
$10,001 - $100,000
FPPC Form 700 (2016/2017) Sch. B
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
700
  
CALIFORNIA FORM
NAME OF LENDER*
ADDRESS (Business Address Acceptable)
  
 
% None
Guarantor, if applicable
 
 
$500 - $1,000 $1,001 - $10,000
$10,001 - $100,000
* 


None
None
Clear Page
Print
Instructions – Schedule C


FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 14

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.
The source and 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

for more information about doing business in the jurisdiction.
Reportable sources of income may be further limited by

interest code.

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.

 
including travel payments provided by your employer
 
report the
employers name and all other required information
 
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
 
(See Reference Pamphlet, page 10, concerning your ability
to receive future honoraria.)
 
12.)
You are not
 Salary, reimbursement for expenses or per diem, or

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

 



 
 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.
 
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. 
commission income on a regular basis or have an
ownership interest of 10% or more, you must disclose

 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.
s Received or Outstanding During the

 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.
 
Reminders
 
disclosure of all sources of income.
 
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.
FPPC Form 700 (2016/2017) Sch. C
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
(Real property, car, boat, etc.) (Real property, car, boat, etc.)

Income, Loans, & Business

(Other than Gifts and Travel Payments)

Noncome - Business Position Only
Noncome - Business Position Only

Name
   
$500 - $1,000 $500 - $1,000
$1,001 - $10,000 $1,001 - $10,000
$10,001 - $100,000 $10,001 - $100,000
700
  
CALIFORNIA FORM
 
 
ADDRESS (Business Address Acceptable)
  
 
 
 
ADDRESS (Business Address Acceptable)
  
 
NAME OF LENDER*
ADDRESS (Business Address Acceptable)
  
 
% None
 
$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
 

   
* You are not required to report loans from commercial lending institutions, or any indebtedness created as part of a


regular course of business must be disclosed as follows:
 
None Personal residence
Real Property
Guarantor
Other
Street address
City
(Describe)
  
Salary  
(For self-employed use Schedule A-2.)
Partnership (Less than 10% ownership. For 10% or greater use
Schedule A-2.)
Sale of
Other
  
Salary  
(For self-employed use Schedule A-2.)
Partnership (Less than 10% ownership. For 10% or greater use
Schedule A-2.)
Sale of
Other
(Describe) (Describe)
(Describe) (Describe)
list each source of $10,000 or more list each source of $10,000 or moreCommission or Commission or
Loan repayment Loan repayment
Clear Page
Print
Instructions – Schedule D
Income – Gifts
Reminders
• Gifts from a single source are subject to a $460 limit
during 2016. See Reference Pamphlet, page 10.
•  you only need to report gifts from
reportable sources.
Gift Tracking Mobile Application
• FPPC has created a gift tracking app for mobile

and easy way to upload the information to the Form

FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons – 16
A gift is anything of value for which you have not provided
equal or greater consideration to the donor. A gift is

multiple gifts totaling $50 or more received during the
reporting period from a single source must be reported.

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.




an intermediary, you must disclose the name, address, and
business activity of both the donor and the intermediary.
You


of Schedule D.

 
 
 
 Food, beverages, and accommodations, including those
provided in direct connection with your attendance at a
convention, conference, meeting, social event, meal, or like
gathering
 

status
 Wedding gifts (See Reference Pamphlet, page 16)
 
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 not
 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
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

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

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

 Free admission, food, and nominal items (such as a pen,
pencil, mouse pad, note pad or similar item) available to


the admission is provided by the person who organizes the
event.
 

made by an individual who is not a lobbyist registered to

gift was made because of an existing personal or business

is no evidence whatsoever at the time the gift is made to


 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.

Income – Gifts

Name
FPPC Form 700 (2016/2017) Sch. D
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
700
  
CALIFORNIA FORM
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
   
DATE   
$
$
$
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
   
DATE   
$
$
$
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
   
DATE   
$
$
$
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
   
DATE   
$
$
$
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
   
DATE   
$
$
$
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
   
DATE   
$
$
$
Clear Page
Print
FPPC Form 700 (2016/2017)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
Instrucons - 18
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specic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 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, 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-prot
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: 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.IfthetraveloccurredonorafterJanuary1,
2016, you must also disclose the travel destination.
- 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 paymen
ts 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 he is not
providing services are
likely considered gifts.
Instructions – Schedule E
Travel Payments, Advances,
and Reimbursements

Income – Gifts
 
and Reimbursements
Name

FPPC Form 700 (2016/2017) Sch. E
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
700

CALIFORNIA FORM





DATE(S):
/ /
-
/ /
AMT: $
(If gift)
DATE(S):
/ /
-
/ /
AMT: $
(If gift)
►NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
CITYAND STATE
501(c)(3)orDESCRIBEBuSINESSACTIvITY,IFANY,OFSOuRCE
►NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
CITYAND STATE
501(c)(3)orDESCRIBEBuSINESSACTIvITY,IFANY,OFSOuRCE
►NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
CITYAND STATE
501(c)(3)orDESCRIBEBuSINESSACTIvITY,IFANY,OFSOuRCE
►NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
CITYAND STATE
501(c)(3)orDESCRIBEBuSINESSACTIvITY,IFANY,OFSOuRCE
►MuSTCHECKONE:
Made aSpeech/Participated in a Panel
Other - Provide Description
Gift  Income
►If Gift, Provide Travel Destination
►MuSTCHECKONE:
Made aSpeech/Participated in a Panel
Other - Provide Description
Gift  Income
►If Gift, Provide Travel Destination
►MuSTCHECKONE:
Made aSpeech/Participated in a Panel
Other - Provide Description
Gift  Income
►If Gift, Provide Travel Destination
►MuSTCHECKONE:
Made aSpeech/Participated in a Panel
Other - Provide Description
Gift  Income
►If Gift, Provide Travel Destination
DATE(S):
/ /
-
/ /
AMT: $
(If gift)
DATE(S):
/ /
-
/ /
AMT: $
(If gift)
Health Services Trade Association
1230 K Street, Suite 610
Sacramento, CA
Association of Healthcare Workers
150.00
Travel reimbursement for
board meeting
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
Income – Gifts

and Reimbursements
Name

FPPC Form 700 (2016/2017) Sch. E
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
700
  
CALIFORNIA FORM





DATE(S): - AMT: $
(If gift)
DATE(S):
- AMT: $
(If gift)
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
 

NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
 

NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
 

NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
 


 
Other - Provide Description
Gift  
f Gift, Provide Travel Destination

 
Other - Provide Description
Gift  
f Gift, Provide Travel Destination

 
Other - Provide Description
Gift  
f Gift, Provide Travel Destination

 
Other - Provide Description
Gift  
f Gift, Provide Travel Destination
DATE(S):
- AMT: $
(If gift)
DATE(S): - AMT: $
(If gift)
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