1. business and industrial

2014/2015 Individual Filer’s Packet
(For Consultants)
Form 700
Statement of Economic Interests
Due April 1, 2015
It’s easier than it looks ● It’s for your peace of mind ● It’s the law
Consultant Checklist
1. Complete the “Cover Page,” Boxes 1-5



Include your firm’s name in Box 1
Check “Type of Statement” in Box 3
Sign & Date the form
2. At the very least, you must also
complete Schedule A-2 or C
3. Make a copy for your records
4. Send original, signed & dated copy to
LAUSD’s Ethics Office
LAUSD Ethics Office
333 S. Beaudry, 20th Fl.
Los Angeles, CA 90017
T: 213-241-3330
F: 213-241-3319
Web: ethics.lausd.net
By law, photo copies and electronic copies of the Form 700 cannot be accepted.
Incomplete forms will be returned automatically to filers for correction.
Sample Information Letter for LAUSD Contractors Required to Complete a Form 700
SEI FILER – LAUSD CONTRACTOR
March 2015
Dear [Insert Name of Your LAUSD Contractor/Consultant]:
As you may be aware from your work with other public agencies, the type of work you perform for LAUSD requires
you to complete and file a Form 700 - Statement of Economic Interests (SEI). Your role designates you as a filer in
accordance with California law because you are involved in making or participating in making decisions on behalf of
LAUSD that could affect private financial interests. State law requires making a public record of personal financial
interests via the Form 700 as a mechanism for ensuring that: all individuals, regardless of whether they are elected,
employed or contracted, who perform duties for a governmental agency avoid any actions that constitute a conflict
of interest.
Under the law, it does not matter if no harm occurred as a result of the conflict. The statute seeks to ensure that
individuals avoid any participation whatsoever in governmental decision-making that affects their interests.
Consultants in roles like yours who influence LAUSD decision-making must file a Form 700 when you first begin
your work with LAUSD, annually thereafter, and when you exit from your work with LAUSD. This letter reminds you
of the annual Form 700 - SEI filing deadline, April 1st this year, which is now fast approaching.
Form 700s can generate the same kind of dread as filing tax returns, but they are much less painful and an
important part of your responsibility as a Consultant for LAUSD. Moreover, you are bound by law to comply with
this disclosure requirement or to face penalties and sanctions otherwise. To make this process as easy and
painless as possible, please use the following schedule of dates and to-dos as a reference:
Key Dates:

3/1
GET READY TO FILE!
Download the interactive PDF Form 700 and other resources from the Ethics Office website at:
http://ethics.lausd.net/seinotice.html - Form 700 Center - so you can be familiar with the filing material.

3/17
COMPLETE THE FORM!
Fill out the cover page and any relevant schedules required of your position and interersts. Sign and
date your SEI to make it an official document. State law requires an original signature on your filing.

3/24
RETURN YOUR STATEMENT!
Submit your signed Form 700 to the Ethics Office. You should also make copy of your own for your
personal records.
If you are a first-time filer, here are a few key points to remember:

Filing is easier than it may seem at first. The Form 700 is notoriously thick and intimidating in appearance, but
for a large majority of Consultants, filing is as simple as completing the cover sheet and Schedule C (especially
if your finances aren’t complex).

There’s a lot of help around. In addition to ample formal resources from the California’s Fair Political Practices
Commission and LAUSD’s Ethics Office, you can tap into LAUSD employees who have been long-time filers.

Don’t delay – April 1st is the hard deadline date by when your filing needs to be received. The law does not
allow a provision for extensions.
Included in your Form 700 packet are a few critical tools and references created by LAUSD’s Ethics Office to assist
you – additional resources are also available on the ethics website at in the “Form 700 Center”:
http://ethics.lausd.net/seinotice.html. If you have any specific questions about the filing requirements, you should
contact California’s Fair Political Practices Commission (FPPC) staff at (866) 275-3772. REMEMBER: Do not
make or participate in the making of financial or governmental decisions regarding your contractor firm or any other
interest disclosed on your Form 700 in your LAUSD capacity.
Thank you in advance for your compliance – not just because it’s the law, but because your efforts help your firm
and LAUSD both demonstrate integrity and build public trust!
Sincerely,
[Insert Name of Division Head Responsible for Contractor/Consultant Contract]
Reference Sheet
Building Trust
Understanding a Conflict of Interest Code
Inside and Out
What is a Conflict of Interest Code?
A Conflict of Interest (COI) Code is the legal framework – established under California’s Political Reform Act of 1974 –
which identifies the officials, employees and consultants working with a local public entity who must file a Form 700
Statement of Economic Interests. The purpose of such financial disclosure is to help individuals be aware of when
they need to be disqualified from participating in government decision-making (i.e. when a financial interest exists),
so that they can avoid a conflict of interest.
A COI Code is made up of three sections: 1) “Introduction” which cites the legal provisions for the Code; 2) “Exhibit A”
which details the categories of financial interests which must be disclosed, and 3) “Exhibit B” which identifies the
positions of individuals charged with making – or participating in making – governmental decisions who are required
to file a Form 700. Individuals designated under a COI Code must satisfy two key requirements: a) disclosure and b)
disqualification to avoid a violation of the Political Reform Act.
What is the Disclosure Requirement?
The Political Reform Act requires designated individuals to disclose their financial interests, including: investments,
real estate (real property) holdings, income, gifts and travel payments received from any sources that might intersect
their public responsibilities. Each position designated to file in Exhibit B is assigned specific disclosure categories from
Exhibit A using a numeric system. Each number corresponds to a particular category of financial interests which must
be disclosed. The broader the scope of decision-making assigned to a position, the more individuals in those positions
may have to disclose.
It is every individual’s personal responsibility to ensure that he/she avoids participating in any governmental decisionmaking involving their financial interests, particularly those that have been identified on a Form 700.
Form 700s must be filed within 30 days of when a designated filer begins public service, annually thereafter (by April
1st each year), and when the designated individual leaves public service (within 30 days).
What is the Disqualification Requirement?
The Political Reform Act requires that designated individuals be disqualified from participation in decision-making
involving their financial interests. This means individuals may NOT take part in discussions, advise on, make
recommendations or otherwise influence or attempt to influence other decision-makers on matters where they have a
financial interest. If during the course of performing government work, an individual is asked to participate in a
matter relating to a financial interest, he/she should notify a supervisor in writing, so that he/she can be disqualified
and the matter reassigned to an individual who is free from conflict. The California Supreme Court has ruled that in
the public sector, the burden is on the individual alone to self-manage against a conflict of interest.
What are the Penalties for Violating the Political Reform Act?
A Conflict of Interest Code has the force of law behind it. Failure to comply with either the disclosure or
disqualification requirements may result in civil and/or criminal penalties, including imprisonment. A violation of the
disclosure provision of the Political Reform Act can result in fines of up to $10,000 or three times the amount an
individual failed to report (depending on which is greater). Similar penalties also apply to violations of the
disqualification provision of the Act. Finally, there can also be a great deal of public scrutiny and embarrassment for
not satisfying what are considered to be basic ethics standards of public service.
How do I use the COI Code to avoid conflicts?
1. Use the Code to find your position title (or one that is similar) and look at the corresponding disclosure categories.
2. Identify the financial interests you have in those categories and disclose accordingly on the appropriate schedule.
3. Remember that when you are disclosing financial interests, you are looking back to at least the past 12 months.
You must also disclose the interests of a spouse or domestic partner (i.e., income received) since they also count
as your interests. Note that most filers will typically complete at least the required cover sheet and Schedule C.
4. Be sure to sign and mail in your Form 700 filing (a wet signature is required and faxes/emails are not acceptable).
5. Keep vigilant about steering clear of participation in any governmental decision-making (again remember that
participation is very broadly defined) involving the interests you have disclosed on your Form 700.
If you need further assistance on filing a Form 700, check out the many online resources at: www.lausd.net/ethics
under the “SEI - Form 700” link. You can also call the state’s Fair Political Practices Commission at: 1-866-ASK-FPPC.
Is there anything else I need to be aware of?
Don’t forget that the Political Reform Act also bans the receipt of honoraria from any reportable source. There are
very specific rules on gifts and what travel payments are allowable as well. Please seek guidance on these as needed.
LAUSD Ethics Office
EO 0709
www.lausd.net/ethics
LAUSD Contractors - About Form 700 Disclosure Categories

What are Disclosure Categories?
Under state law, every Form 700 filer is assigned disclosure categories using a numeric system.
Each number corresponds to a particular category of financial interests which must be disclosed.
The broader the scope of decision-making assigned to a position, the greater the disclosure level
for an individual in that position.
All contractors/consultants who meet the disclosure trigger start out at disclosure level 6 which is
the generic category for consultants. Specific categories are then assigned by the LAUSD
contract sponsor in conjunction with the Ethics Office based on the type of advice or decisionmaking LAUSD has contracted with the filer and the filer’s firm to provide.
Disclosure Levels
Full
Disclosure
Medium
Disclosure
Partial
Disclosure
(1,2,3)
(1,4)
(4)
Scope of Your Work for LAUSD
Broad
Narrow
Narrow
Potential to Affect Real Property
Potential to Affect Real Property
NO Potential to Affect Real Property
A contractor/consultant that
would be required to file at the
Medium Disclosure level
participates in the making of
LAUSD decisions relating to a
narrow range of issues,
including issues involving real
property interests.
A contractor/consultant that
would be required to file at the
Partial Disclosure level
participates in the making of
LAUSD decisions relating to a
narrow range of issues and
has NO involvement in issues
relating to real property
interests.
 Project Manager I & II
 Construction Managers
 Outside Counsel on
Facilities Issues
 IT Consultant
 Financial Adviser to LAUSD
 Outside Counsel
ALL:
ALL:
ALL EXCEPT SCHEDULE B
 A-1, A-2, B, C, D, E
 A-1, A-2, B, C, D, E
 A-1, A-2, C, D, E
A contractor/consultant that
would be required to file at the
Full Disclosure level
participates in the making of
LAUSD decisions relating to a
broad range of issues across
different parts of the
organization, including issues
involving real property
interests.
Examples of Positions
 Performance Review
Consultant
 Acting Senior Deputy
Schedules You Should Review

Who should I contact if I’m unsure of which Disclosure Categories to comply with?
If you are still unsure of which category you should file under, please check with your firm’s
LAUSD contact, so that they can let you know the disclosure categories which have been
assigned to your position by your LAUSD contract sponsor.
ETHICS TOOL
Form 700 - Statement of Economic Interests (SEI)
Ethics Office
Building Trust
About the Schedules
Inside and Out
Whether you need to complete a schedule depends on your disclosure category(ies) & personal finances:
Note: This sheet covers
the most common items,
but it is by no means
exhaustive. If your
finances are more complex, please review the
Form 700 directions in full.
SCHEDULE:
USED FOR
A1
A2
B
C
D
Income & Loans
Gifts
REPORTING:
Investments
Investments
Real Property
(Ownership Interest <10%)
(Ownership Interest >10%)
(Including Rental Income)
YOU MUST
DISCLOSE*:
• Business(es) you own
• Partnerships or other
• Business(es) you own
• Partnerships or other
ownership interests
• Individual stocks,
bonds, warrants, etc.
ownership interests
• Individual stocks,
bonds, warrants, etc.
* IF YOUR INTEREST
IS REPORTABLE AS
PER YOUR CATEGORY
NOT REQUIRED • SEC Mutual Funds
• Private bank accounts
TO DISCLOSE:
• All interests in real
property located within
2 miles of LAUSD’s
boundaries
• Any income >$500
(before taxes, etc.)
• Any loans made on
terms for you (i.e. not
publicly available)
•
•
•
•
Meals
Tickets & Passes
Wedding gifts
Holiday gifts
(Including Advances &
Reimbursements)
• Payments for travel
related expenses,
including lodging and
meals
• PERS/STRS accounts
• Government bonds
If you, your spouse, your
domestic partner, or
dependent child has an
interest over $2000, it
needs to be disclosed
If you, your spouse, your
domestic partner, or
dependent child has an
interest >10%, and valued
over $2000, disclose it!
Real property interests
held by a business you
own, your domestic
partner, or your spouse
owns must be disclosed
If your spouse or your domestic partner works for a
company that is a reportable interest, their income
needs to be disclosed too
All gifts over $50 must be
reported along with
multiple gifts totaling $50
or more, from a single
source
Travel payments always
count as either a gift or
income, based on the type
of service you provide
CASE IN POINT: You are a partner with a
You wholly own your
home-based business.
You must report its value
& your income and also
identify specific sources of
income over $10,000.
You own rental property
in San Diego and get
income from a tenant.
This is not reportable
because the property isn’t
in LAUSD’s jurisdiction.
Your spouse works for a
private company that provides services in an area
of your influence. You
need to report 50% of
your spouse’s income.
A vendor you make decisions on takes you to two
$30 lunches. Since the
cumulative value is over
$50, both lunches would
need to be reported.
You’re a board member for
a nonprofit which reimburses you for a board
retreat. Your travel, lodging
& meals count as income
and need to be reported.
SPECIAL
NOTES:
5% ownership interest in
the ACME company. You
must disclose the value of
your share. Any income
would go on Schedule C.
• Gifts from family
• Gifts you reciprocate
Travel Payments
•
•
•
•
SEC Mutual Funds
Private bank accounts
PERS/STRS accounts
Government bonds
• Your primary residence • Payments from any
government agencies
• Your vacation home
These exceptions hold as long as • Commercial loans
you don’t claim a business
• Alimony
deduction on these residences
E
with equal value for
holidays, birthdays, etc.
• Travel payments from
LAUSD and any other
governmental agencies
CALIFORNIA FORM
700
Date Initial Filing
Received
STATEMENT OF ECONOMIC INTERESTS
FAIR POLITICAL PRACTICES COMMISSION
Official Use Only
COVER PAGE
A PUBLIC DOCUMENT
Please type or print in ink.
NAME OF FILER
(LAST)
(FIRST)
(MIDDLE)
1. Office, Agency, or Court
Agency Name (Do not use acronyms)
Los Angeles Unified School District
Division, Board, Department, District, if applicable (LAUSD Division-Firm) Your Position (Consultant - LAUSD Title)
Consultant ►
If filing for multiple positions, list below or on an attachment. (Do not use acronyms)
Position:
Agency:
2. Jurisdiction of Office
(Check at least one box)
State
Judge or Court Commissioner (Statewide Jurisdiction)
Multi-County
County of
City of
✔ Other
3. Type of Statement
(Check at least one box)
Annual: The period covered is January 1, 2014, through
December 31, 2014.
-or-
Portion of LA County (LAUSD)
The period covered is
December 31, 2014.
Assuming Office: Date assumed
/
/
/
Leaving Office: Date Left
(Check one)
/
The period covered is January 1, 2014, through the date of
leaving office.
, through
The period covered is
the date of leaving office.
/
Candidate: Election year
/
/
/
, through
and office sought, if different than Part 1:
4. Schedule Summary
Check applicable schedules or “None.”
►
Total number of pages including this cover page:
Schedule A-1 - Investments – schedule attached
Schedule C - Income, Loans, & Business Positions – schedule attached
Schedule A-2 - Investments – schedule attached
Schedule D - Income – Gifts – schedule attached
Schedule B - Real Property – schedule attached
Schedule E - Income – Gifts – Travel Payments – schedule attached
-or-
None - No reportable interests on any schedule
5. Verification
MAILING ADDRESS
STREET
(Business or Agency Address Recommended - Public Document)
DAYTIME TELEPHONE NUMBER
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
( )
I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained
herein and in any attached schedules is true and complete. I acknowledge this is a public document.
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date Signed
Clear Page
(month, day, year)
Print Form
Signature
(File the originally signed statement with your filing official.)
FPPC Form 700 (2014/2015)
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
SCHEDULE A-1
Investments
Stocks, Bonds, and Other Interests
(Ownership Interest is Less Than 10%)
CALIFORNIA FORM
700
FAIR POLITICAL PRACTICES COMMISSION
Name
Do not attach brokerage or financial statements.
► NAME OF BUSINESS ENTITY
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
FAIR MARKET VALUE
$2,000 - $10,000
$100,001 - $1,000,000
$10,001 - $100,000
Over $1,000,000
NATURE OF INVESTMENT
Stock
Other
Partnership
(Describe)
Income Received of $0 - $499
Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/
/ 14
$10,001 - $100,000
Over $1,000,000
NATURE OF INVESTMENT
Stock
Other
Partnership
(Describe)
Income Received of $0 - $499
Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/
ACQUIRED
$2,000 - $10,000
$100,001 - $1,000,000
/ 14
DISPOSED
► NAME OF BUSINESS ENTITY
/
/ 14
/
ACQUIRED
/ 14
DISPOSED
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
FAIR MARKET VALUE
$2,000 - $10,000
$100,001 - $1,000,000
$10,001 - $100,000
Over $1,000,000
NATURE OF INVESTMENT
Stock
Other
Partnership
(Describe)
Income Received of $0 - $499
Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/
/ 14
$10,001 - $100,000
Over $1,000,000
NATURE OF INVESTMENT
Stock
Other
Partnership
(Describe)
Income Received of $0 - $499
Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/
ACQUIRED
$2,000 - $10,000
$100,001 - $1,000,000
/ 14
DISPOSED
► NAME OF BUSINESS ENTITY
/
/ 14
/
ACQUIRED
/ 14
DISPOSED
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
FAIR MARKET VALUE
$2,000 - $10,000
$100,001 - $1,000,000
$10,001 - $100,000
Over $1,000,000
NATURE OF INVESTMENT
Stock
Other
Partnership
(Describe)
Income Received of $0 - $499
Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/
/ 14
ACQUIRED
$2,000 - $10,000
$100,001 - $1,000,000
$10,001 - $100,000
Over $1,000,000
NATURE OF INVESTMENT
Stock
Other
Partnership
(Describe)
Income Received of $0 - $499
Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/
/ 14
DISPOSED
/
/ 14
ACQUIRED
/
/ 14
DISPOSED
Comments:
Clear Page
Print Form
FPPC Form 700 (2014/2015) Sch. A-1
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
SCHEDULE A-2
Investments, Income, and Assets
of Business Entities/Trusts
700
CALIFORNIA FORM
FAIR POLITICAL PRACTICES COMMISSION
Name
(Ownership Interest is 10% or Greater)
►1. BUSINESS ENTITY OR TRUST
►1. BUSINESS ENTITY OR TRUST
Name
Name
Address (Business Address Acceptable)
Address (Business Address Acceptable)
Check one
Trust, go to 2
Check one
Trust, go to 2
Business Entity, complete the box, then go to 2
GENERAL DESCRIPTION OF THIS BUSINESS
GENERAL DESCRIPTION OF THIS BUSINESS
IF APPLICABLE, LIST DATE:
FAIR MARKET VALUE
$0 - $1,999
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
/ 14
/
/
ACQUIRED
NATURE OF INVESTMENT
Partnership
Sole Proprietorship
/ 14
DISPOSED
Other
$10,001 - $100,000
OVER $100,000
►4. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD OR
LEASED BY THE BUSINESS ENTITY OR TRUST
Check one box:
Other
$10,001 - $100,000
OVER $100,000
►4. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD OR
LEASED BY THE BUSINESS ENTITY OR TRUST
Check one box:
REAL PROPERTY
INVESTMENT
REAL PROPERTY
Name of Business Entity, if Investment, or
Assessor’s Parcel Number or Street Address of Real Property
Name of Business Entity, if Investment, or
Assessor’s Parcel Number or Street Address of Real Property
Description of Business Activity or
City or Other Precise Location of Real Property
Description of Business Activity or
City or Other Precise Location of Real Property
FAIR MARKET VALUE
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
FAIR MARKET VALUE
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
IF APPLICABLE, LIST DATE:
/
NATURE OF INTEREST
Property Ownership/Deed of Trust
Leasehold
Yrs. remaining
/ 14
/
/ 14
ACQUIRED
DISPOSED
Stock
Partnership
Other
Check box if additional schedules reporting investments or real property
are attached
Comments:
Clear Page
/ 14
►3. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF
INCOME OF $10,000 OR MORE (Attach a separate sheet if necessary.)
or
None
Names listed below
Names listed below
INVESTMENT
/
DISPOSED
►2. IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA
SHARE OF THE GROSS INCOME TO THE ENTITY/TRUST)
$0 - $499
$500 - $1,000
$1,001 - $10,000
►3. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF
INCOME OF $10,000 OR MORE (Attach a separate sheet if necessary.)
or
/ 14
/
ACQUIRED
YOUR BUSINESS POSITION
►2. IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA
SHARE OF THE GROSS INCOME TO THE ENTITY/TRUST)
None
IF APPLICABLE, LIST DATE:
FAIR MARKET VALUE
$0 - $1,999
$2,000 - $10,000
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
NATURE OF INVESTMENT
Partnership
Sole Proprietorship
YOUR BUSINESS POSITION
$0 - $499
$500 - $1,000
$1,001 - $10,000
Business Entity, complete the box, then go to 2
Print Form
IF APPLICABLE, LIST DATE:
/
NATURE OF INTEREST
Property Ownership/Deed of Trust
Leasehold
Yrs. remaining
/ 14
/
/ 14
ACQUIRED
DISPOSED
Stock
Partnership
Other
Check box if additional schedules reporting investments or real property
are attached
FPPC Form 700 (2014/2015) Sch. A-2
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
700
CALIFORNIA FORM
SCHEDULE B
Interests in Real Property
FAIR POLITICAL PRACTICES COMMISSION
Name
(Including Rental Income)
► ASSESSOR’S PARCEL NUMBER OR STREET ADDRESS
► ASSESSOR’S PARCEL NUMBER OR STREET ADDRESS
CITY
CITY
FAIR MARKET VALUE
$2,000 - $10,000
IF APPLICABLE, LIST DATE:
/ 14
/
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
ACQUIRED
/
/ 14
DISPOSED
NATURE OF INTEREST
Easement
Yrs. remaining
Other
IF RENTAL PROPERTY, GROSS INCOME RECEIVED
$0 - $499
$500 - $1,000
$1,001 - $10,000
OVER $100,000
$10,001 - $100,000
SOURCES OF RENTAL INCOME: If you own a 10% or greater
interest, list the name of each tenant that is a single source of
income of $10,000 or more.
None
*
IF APPLICABLE, LIST DATE:
/ 14
/
$10,001 - $100,000
$100,001 - $1,000,000
Over $1,000,000
ACQUIRED
/
/ 14
DISPOSED
NATURE OF INTEREST
Ownership/Deed of Trust
Leasehold
FAIR MARKET VALUE
$2,000 - $10,000
Ownership/Deed of Trust
Leasehold
Easement
Yrs. remaining
Other
IF RENTAL PROPERTY, GROSS INCOME RECEIVED
$0 - $499
$500 - $1,000
$1,001 - $10,000
OVER $100,000
$10,001 - $100,000
SOURCES OF RENTAL INCOME: If you own a 10% or greater
interest, list the name of each tenant that is a single source of
income of $10,000 or more.
None
You are not required to report loans from commercial lending institutions made in the lender’s regular course of
business on terms available to members of the public without regard to your official status. Personal loans and
loans received not in a lender’s regular course of business must be disclosed as follows:
NAME OF LENDER*
NAME OF LENDER*
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF LENDER
BUSINESS ACTIVITY, IF ANY, OF LENDER
INTEREST RATE
INTEREST RATE
%
TERM (Months/Years)
None
%
HIGHEST BALANCE DURING REPORTING PERIOD
TERM (Months/Years)
None
HIGHEST BALANCE DURING REPORTING PERIOD
$500 - $1,000
$1,001 - $10,000
$500 - $1,000
$1,001 - $10,000
$10,001 - $100,000
OVER $100,000
$10,001 - $100,000
OVER $100,000
Guarantor, if applicable
Guarantor, if applicable
Comments:
Clear Page
Print Form
FPPC Form 700 (2014/2015) Sch. B
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
SCHEDULE C
Income, Loans, & Business
Positions
CALIFORNIA FORM
700
FAIR POLITICAL PRACTICES COMMISSION
Name
(Other than Gifts and Travel Payments)
► 1. INCOME RECEIVED
► 1. INCOME RECEIVED
NAME OF SOURCE OF INCOME
NAME OF SOURCE OF INCOME
(Firm's Information)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
BUSINESS ACTIVITY, IF ANY, OF SOURCE
YOUR BUSINESS POSITION
YOUR BUSINESS POSITION
GROSS INCOME RECEIVED
GROSS INCOME RECEIVED
$500 - $1,000
$10,001 - $100,000
$1,001 - $10,000
OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
Salary
Spouse’s or registered domestic partner’s income
(For self-employed use Schedule A-2.)
$500 - $1,000
$1,001 - $10,000
OVER $100,000
$10,001 - $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
Salary
Spouse’s or registered domestic partner’s income
(For self-employed use Schedule A-2.)
Partnership (Less than 10% ownership. For 10% or greater use
Partnership (Less than 10% ownership. For 10% or greater use
Sale of
Sale of
Schedule A-2.)
(Real property, car, boat, etc.)
Loan repayment
Commission or
Schedule A-2.)
(Real property, car, boat, etc.)
Loan repayment
Rental Income, list each source of $10,000 or more
Commission or
Rental Income, list each source of $10,000 or more
(Describe)
Other
(Describe)
(Describe)
Other
(Describe)
► 2. LOANS RECEIVED OR OUTSTANDING DURING THE REPORTING PERIOD
*
You are not required to report loans from commercial lending institutions, or any indebtedness created as part of a
retail installment or credit card transaction, made in the lender’s regular course of business on terms available to
members of the public without regard to your official status. Personal loans and loans received not in a lender’s
regular course of business must be disclosed as follows:
NAME OF LENDER*
INTEREST RATE
%
ADDRESS (Business Address Acceptable)
TERM (Months/Years)
None
SECURITY FOR LOAN
BUSINESS ACTIVITY, IF ANY, OF LENDER
None
Personal residence
Real Property
HIGHEST BALANCE DURING REPORTING PERIOD
$500 - $1,000
Street address
City
$1,001 - $10,000
Guarantor
$10,001 - $100,000
OVER $100,000
Other
(Describe)
Comments:
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Print Form
FPPC Form 700 (2014/2015) Sch. C
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
CALIFORNIA FORM
SCHEDULE D
Income – Gifts
Name
► NAME OF SOURCE (Not an Acronym)
► NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy)
VALUE
DESCRIPTION OF GIFT(S)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy)
VALUE
DESCRIPTION OF GIFT(S)
/
/
$
/
/
$
/
/
$
/
/
$
/
/
$
/
/
$
► NAME OF SOURCE (Not an Acronym)
► NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy)
VALUE
DESCRIPTION OF GIFT(S)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy)
VALUE
DESCRIPTION OF GIFT(S)
/
/
$
/
/
$
/
/
$
/
/
$
/
/
$
/
/
$
► NAME OF SOURCE (Not an Acronym)
► NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy)
VALUE
DESCRIPTION OF GIFT(S)
700
FAIR POLITICAL PRACTICES COMMISSION
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy)
VALUE
DESCRIPTION OF GIFT(S)
/
/
$
/
/
$
/
/
$
/
/
$
/
/
$
/
/
$
Comments:
Clear Page
Print Form
FPPC Form 700 (2014/2015) Sch. D
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
CALIFORNIA FORM
SCHEDULE E
Income – Gifts
Travel Payments, Advances,
and Reimbursements
700
FAIR POLITICAL PRACTICES COMMISSION
Name
• Mark either the gift or income box.
• Mark the “501(c)(3)” box for a travel payment received from a nonprofit 501(c)(3) organization
or the “Speech” box if you made a speech or participated in a panel. These payments are not
subject to the $440 gift limit, but may result in a disqualifying conflict of interest.
► NAME OF SOURCE (Not an Acronym)
► NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
CITY AND STATE
501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE
CITY AND STATE
501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE(S):
/
/
(If gift)
/
/
TYPE OF PAYMENT: (must check one)
AMT:$
Gift
DATE(S):
/
/
(If gift)
/
/
TYPE OF PAYMENT: (must check one)
Income
Gift
Made a Speech/Participated in a Panel
Made a Speech/Participated in a Panel
Other - Provide Description
Other - Provide Description
► NAME OF SOURCE (Not an Acronym)
► NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
AMT:$
CITY AND STATE
501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE
Income
CITY AND STATE
501 (c)(3) or DESCRIBE BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE(S):
/
/
(If gift)
/
/
TYPE OF PAYMENT: (must check one)
DATE(S):
AMT:$
Gift
Income
/
/
(If gift)
/
/
TYPE OF PAYMENT: (must check one)
AMT:$
Gift
Made a Speech/Participated in a Panel
Made a Speech/Participated in a Panel
Other - Provide Description
Other - Provide Description
Income
Comments:
Clear Page
Print Form
FPPC Form 700 (2014/2015) Sch. E
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov