Fill - Free fillable Form 700 2016 2017 Full Document (California State University Channel Islands) PDF form

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 year’s 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



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

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

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

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

or

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

lender’s 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



 

%

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

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

 

 

%

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

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

 

 

% 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

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

employer’s 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.

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.

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

•

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

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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Fill Online, Printable, Fillable, Blank Form 700 2016 2017 Full Document (California State University Channel Islands) Form

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Fillable Form 700 2016 2017 Full Document (California State University Channel Islands)

Fill Online, Printable, Fillable, Blank Form 700 2016 2017 Full Document (California State University Channel Islands) Form

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