Fill - Free fillable Form700 U-09 10 CSU%5B1%5D (California State University Channel Islands) PDF form

or greater. Income includes your gross income and your

community property interest in your spouse’s or registered

domestic partner’s gross income totaling $500 or more.

Gross income is the total amount of income before deducting

expenses, losses, or taxes. (See Gov. Code Section 82030.)

What is a Loan?

Loans received or outstanding are reportable if they total

$500 or more from a single lender. Your community

property interest in loans received by your spouse or

registered domestic partner also must be reported. (See

Gov. Code Section 82030(a).)

What is a Gift?

A gift is anything of value for which you have not provided

equal or greater consideration to the donor. A gift is

reportable if its fair market value is $50 or more. In

addition, multiple gifts totaling $50 or more received from a

reportable source must be reported.

It is the acceptance of a gift, not the ultimate use to which

it is put, that imposes your reporting obligation. Therefore

you must report a gift even if you never used it or if you

gave it away to another person.

If the exact amount of a gift is not known, you must make a

good faith estimate of the item’s fair market value. Listing

the value of a gift as “over $50” or “value unknown” is not

adequate disclosure.

Commonly reportable gifts include:

• Tickets/passes to sporting or entertainment events

• Tickets/passes to amusement parks

• Parking passes

• Food, beverages, and accommodations, including that

provided in direct connection with your attendance at

a convention, conference, meeting, social event, meal,

or like gathering, where you did not give a speech,

participate in a panel or seminar, or provide a similar

service

• Rebates/discounts not made in the regular course of

business to members of the public without regard to

ofcialstatus

• Wedding gifts

• An honorarium. You may report an honorarium as

income rather than as a gift if you provided services of

equal or greater value than the payment received.

• Transportation and lodging

• Forgiveness of a loan received by you

(See Gov. Code Section 82028.)

FPPC Form 700-U (2009/2010)

FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov

Who Files Form 700-U?

ThisformmustbeledbyallpersonsemployedbyUCor

CSUwhohaveprincipalresponsibilityforaresearchproject

iftheprojectistobefundedorsupported,inwholeorin

part, by a contract or grant (or other funds earmarked by

thedonorforaspecicresearchprojectorforaspecic

researcher) from a nongovernmental entity.

Reporting requirements are outlined in Regulation 18755.

This regulation provides that research funding by certain

nonprotentitieswillnottriggerdisclosure.Thisregulationis

available on the FPPC website.

What is the Reporting Period?

For"initial"statements,beforethenalacceptanceofthe

contract,grant,orgift,thelermustreportinvestmentsin

and business positions with the sponsor as of the date that

the award is made, and income and gifts received from

the sponsor within the 12 months prior to the date that the

award is made.

For"interim"statements,thelermustsubmitastatement

within 30 days after the contract, grant, or gift is renewed

that discloses reportable investments, income and

businesspositionsthatthelerheldorreceivedduringthe

periodbetweenthedatetheinitialstatementwasledand

thedatetheprojectcontract,grant,orgiftwasrenewed.

What is an Investment?

“Investment”meansanynancialinterestinabusiness

entity in which you, your spouse or registered domestic

partner, or your dependent children have a direct, indirect,

orbenecialinteresttotaling$2,000ormore.Reportable

investments include stocks, bonds, warrants, and options,

including those held in margin or brokerage accounts and

investment funds. Common examples of investment funds

are index funds, exchange-traded funds, and venture capital

funds. (See Gov. Code Section 82034.)

What is Income?

“Income” means a payment received, including but not limited

to any salary, wage, advance, dividend, interest, rent, proceeds

from any sale, gift, including any gift of food or beverage, loan

forgivenessorpaymentofindebtednessreceivedbytheler,

reimbursement for expenses, per diem, or contribution to an

insurance or pension program paid by any person other than

an employer, and any community property interest in income

of a spouse or registered domestic partner. Income also

includes an outstanding loan. Income of an individual also

includes a pro rata share of any income of any business entity

or trust in which the individual, spouse, or registered domestic

partnerownsdirectly,indirectly,orbenecially,a10%interest

Instructions for Completing

Form 700-U

700-U

CALIFORNIA

FORM

A. Areyou adirector,ofcer,partner,trustee,consultant,

employee, or do you hold a position of management in

the entity listed in Part 1? No

Yes

Title:

Initial (for new funding)

Date of initial funding: / /

STATEMENT OF ECONOMIC INTERESTS

FOR

PRINCIPAL INVESTIGATORS

A Public Document

NAME (LAST) (FIRST) (MIDDLE)

ACADEMICUNITORDEPARTMENT MAILCODE

( )

TELEPHONENUMBER

FPPC Form 700-U (2009/2010)

FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov

Name of Entity:

Address of Entity:

PrincipalBusiness ofEntity:

Amount of Funding: $

Estimated

Actual

3. Filer Information

1. Information Regarding Funding Entity

(Usea separateForm 700-Ufor eachfunding entity.)

3. Filer Information - Cont.

E-MAIL ADDRESS

Date Received

Campus Use Only

Please type or print in ink.

700-U

FAIR POLITICAL PRACTICES COMMISSION

CALIFORNIA

FORM

2. Type of Statement (Check at least one box)

Interim (for renewed funding)

Funding was renewed on: / /

E. Have you received gifts from the entity listed in Part 1

within the last 12 months valued at $50 or more?

Yes

– describe below.

Description:

Value: $ Date Received: / /

D. Have you received loans from the entity in Part 1 for which

the balance exceeded $500 during the reporting period?

Yes

– highest balance:

$500 - $1,000 $1,001 - $10,000

$10,001 - $100,000 Exceeded $100,000

If you checked “yes,” was the loan:

Secured Unsecured Interestrate: %

Was the loan entirely repaid within the last 12 months?

No Yes

Campus:

ID No:

B. Doyou, yourspouse orregistered domesticpartner,or

your dependent children have an investment of $2,000

or more in the entity listed in Part 1 above?

Yes

– value is:

$2,000 - $10,000 $10,001 - $100,000

$100,001 - $1,000,000 Exceeds $1,000,000

Date Disposed:

/ / , if applicable

Description:

Amt: $ date(s): / / / /

(If applicable)

Type of Payment: (check one) Gift Income

F. Has the entity in Part 1 paid for your travel during the

reporting period

? No

Yes

– describe below.

4. Verication

I have used all reasonable diligence in preparing this statement. I

have reviewed this statement and to the best of my knowledge the

information contained herein and in any attached schedules is true

andcomplete.Icertifyunderpenaltyofperjuryunderthelawsof

the State of California that the foregoing is true and correct.

Date Signed

(month, day, year)

Signature

(File the originally signed statement with your university.)

The Form 700-U is for university use only.

This statement is a public record under Gov. Code Section 81008(a).

TITLEOFRESEARCHPROJECT

C. Have you received income of $500 or more from the

entity listed in Part 1 during the reporting period?

Yes

– amount is:

$500 - $1,000 $1,001 - $10,000

$10,001 - $100,000 Exceeds $100,000

Was this income received through your spouse or

registered domestic partner?

No Yes

Completion Statement, CSU Req. Project ended:

Clear Form

Print Form

• Food, beverages, and necessary accommodations

received directly in connection with an event held inside

or outside California at which you gave a speech,

participated in a panel, or provided a similar service

(note that payments for transportation outside of

California are reportable)

• Atravelpaymentwhich wasreceivedfromanonprot

entity exempt from taxation under IRS Code Section

501(c)(3) for which you provided equal or greater

consideration

Check the box to indicate if the payment was a gift or

income, report the amount, and disclose the date(s) if

applicable.

Violations

FailuretoletherequiredStatementofEconomicInterests

orfailuretoreportanancialinterestmaysubjecta

principalinvestigatortocivilliability,includingnes,as

wellasUniversitydiscipline.(Gov.CodeSections81000-

91014)

Privacy Information Notice

Information requested on all FPPC forms is used by the

FPPC to administer and enforce the Political Reform

Act (Gov. Code Sections 81000-91014 and Regulations

18109-18997). All information required by these forms is

mandated by the Political Reform Act. Failure to provide

all of the information required by the Act is a violation

subjecttoadministrative,criminalorcivilprosecution.All

reports and statements provided are public records open

for public inspection and reproduction.

If you have any questions regarding this Privacy Notice or

how to access your personal information, please contact

the FPPC at:

General Counsel

Fair Political Practices Commission

428JStreet,Suite620

Sacramento, CA 95814

(916)322-5660

What is a Travel Payment?

Travel payments include advances and reimbursements

for travel and related expenses, including lodging and

meals.

• Travel payments are gifts if you did not provide

services which were equal to or greater in value

than the payments received. You must disclose gifts

totaling $50 or more from a single source during

the period covered by the statement. Gifts of travel

are reportable without regard to where the donor is

located.

When reporting travel payments which are gifts, you

must provide a description of the gift and the date(s)

received.

Travel payments are income if you provided services

which were equal to or greater in value than the

payments received. You must disclose income

totaling $500 or more from a single source during the

periodcoveredby thestatement. The lerhasthe

burden of proving the payments are income rather

than gifts.

When reporting travel payments as income, you must

describe the services you provided in exchange for

the payment. You are not required to disclose the

date(s) for travel payments which are income.

Giftsoftravelmaybe subjecttoa $420giftlimit.In

addition, certain travel payments are reportable gifts, but

arenotsubjecttothe giftlimit. SeetheFPPCfactsheet

entitled “Limitations and Restrictions on Gifts, Honoraria,

Travel, and Loans,” which can be obtained from the

FPPC at www.fppc.ca.gov.

You are not required to disclose:

• Travel payments received from any state, local, or

federal government agency for which you provided

services equal or greater in value than the payments

received

• Travel payments received from your employer in the

normal course of your employment

• Payments or reimbursements for transportation within

California in connection with an event at which you

gave a speech, participated in a panel or seminar, or

performed a similar service

Instructions for Completing

Form 700-U (continued)

700-U

CALIFORNIA

FORM

FPPC Form 700-U (2009/2010)

FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov

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