Please type or pdnt in ink.
NAME OF FILER
1. Office, Agency, or Court
(LAST) (FIRST)
20 I: O0 (MIDDLE)
Agency Name
Division, Board, Department, District, if applicable Your Position
~ If filing for multiple positions, list below or on an attachment.
Agency: Position: ,
=
Jurisdiction of Office (Check at least one box)
~i¢State
[] Multi-County
[] city of
[~udge or Court Commissioner (Statewide Jurisdiction)
~’County of L¢.�.~ /ozlo~,.,~z.~
[] Other
J Type of Statement (Check at least one box)
[] Annual: The period covered is January 1, 2012, through December 31, 2012.
The period covered is __J / December 31, 2012.
[] Assuming Office: Date assumed __/ L
, through
Leaving Office: Date Left / / (Check one)
O The period covered is January 1, 2012, through the date of leaving office.
O The period covered is J / , through the date of leaving office.
[] Candidate: Election year and office sought, if different than Part 1:
=
Schedule Summary Check applicable schedules or "None."
~Schedule A-1 - Investments - schedule attached
[~chedule A-2 - Investments - schedule attached
~chedule B - Real Property- schedule attached
¯ Total number of pages including this cover page: / t/
~"¢"Schedule C - Income, Loans, & Business Positions - schedule attached
~"! Schedule D - Income - Gifts - schedule attached ~/~chedule E - Income - Gifts - Travel Payments - schedule attached
-or-
[] None - No reportable interests on any schedule
I certify under penalW _/~ry under the laws of the State
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%)
Do not attach brokerage or financial statements.
/�
SPDR S&P 500 ETF TR Tracks the S&P 500 Index $100.001 - $1,000.000 ETF
JPMorgan Strategic Income Opportunties Fund Fund invests in range of FI products $100.001 - $1,000.000 Mutual Fund
iShares MSCi EAFE Index Fund Tracks the MSCI EAFE Index $100.001 - $1,000,000 ETF
Powershares DB Commodity Fund Tracks the D£~ Commodit7 Index $10,001 - $100.000 ETF
iShares Barclays Aggregate Bond Fund Tracks the Barlcays Aggregate bond Index $100.001 - $1,000,000 ETF
TCW Total Return Bond Fund Fund seeks to achieve total return $10,001 - $100,000 Mutual Fund
Double Line Total Return Bond Fuod ¯ Fund seeks to achieve total return $100,001 - $1.000.000 Mutual Fund 11/20/2012
iShares Emerg Mkt Min Vol Fund Tracks the MSCI Em Mid Min Vol Index $2,000 - $10.000 ETF 11115/2012
Vanguard MSCI Emerging Markets ETF Tracks the MSCI Em Mid Index $2,000 - $10.000 ETF
Vanguard EXTD Market ETF Tracks benchmarks for stocks sm to mid $10.001 - $100.000 ETF
Oppenheimer Senior Floating Rate Fund Fund invests In floating rate notes FI $10.001 - $100.000 Mutual Fund
LShares MSCI EAFE Index Fund Tracks the MSCI EAFE Index $2.000 - $10.000 ETF
FPPC Form 700 (2011/2012) Soh. A-lx
FPPC Toll-Free Helpline: 86SlASK-FPPC www.fppo.©a.gov
* Select from drop down list
SCHEDULE A-2
Investments, Income, and Assets
of Business Entities/Trusts (Ownership Interest is 10% or Greater)
Name
LIST DATE NAME AND ADDRESS OF BUSINESS GENERAL
ACQUIRED ENTITY OR TRUST DESCRIPTION OF FAIR MARKET
OR (Business Address Acceptable) BUSINESS VALUE*
DISPOSED (If Trust, go to 2) ACTIVITY
(mnddd/2012)
The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga B. Weinh~ch The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga B. Weinbach The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga
B. W~inhach The Elia and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga
R W~inbach The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga
B. W~inbach The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga B. Weinbach The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga
~, We-inhach The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80
Separate Property Trust of Helga
B. Weinbach
NATURE OF A
INVESTMENT YOUR BUSINESS or
D (if "other," POSITION
descdbe)*
INCLUDE YOUR
PRO RATA
SHARE OF
GROSS
INC(~ME TO
ENTITYFFRUS’P
LIST SINGLE
SOURCES OF
INCOME OF
$10,000 OR MORE
INVESTMENT- REAL PROPERTY-
BUSINESS LIST PRECISE FAIR MARKET
ENTITYINAME, AND LOCATION OF VALUE*
BUSINESS ACTIVITY REAL PROPERTY
$100,001-
$1,000,000
iShares Trust Russell 2000 1 $100,001-
$1,000,000
iShares Trust Russell EO00 (
$1oo,ool-
$1,ooo,ooo
iShares MSCI EAFE Index Fu $100,001-
$1,000,000
SPDR 5&P Midcap 400 ETF
SPDR S&P 500 ETF $10,001 -
$100,000
Univ CA AMBAC Pre-Refun~ $1 o,001 -
$10o,0oo
Univ CA AMBAC Pre-Refun( $2,000 -
$10,000
CA ST Econ Recovery
LIST DATE NATURE OF
ACQUIRED A INTEREST
OR or
DISPOSED D (if"other,"
descdbe)* (mm/dd12012)
ETF
ETF
ETF
ETF
$100,001 - ETF
$1,000,000
Bond
Bond
Bond
FPPC Form 700 (201112012) Sch. A-2x FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov
~ SelectJ:rom drop down fist
SCHEDULE A-2
Investments, Income, and Assets of Business Entities/Trusts
(Ownership Interest is 10% or Greater) Name
LIST DATE NAME AND ADDRESS OF BUSINESS GENERAL
ACQUIRED DESCRIPTION OF FAIR MARKET
OR VALUE*
DISPOSED (If Trust, go to 2) ACTIVITY
(mnddd/2012)
The Ella and Helga B Weinbach
Family Trust, dtd 12/23/80,
Separate Property Trust of Helga B. Weinb~ch The Elia and Helga B Weinbach
Family Trust, dtd 12/23/80,
Separate Property Trust of Helga
The Elia and Helga B Weinbach
Family Trust, dtd 12/23180,
Separate Property Trust of Helga
The Elia and Helga B Weinbach
Family Trust, dtd 12/23180,
Separate Property Trust of Helga B W~inbach The Elia and Helga B Weinbach
Family Trust, dtd 12/23/80,
Separate Property Trust of Helga
~ W~inbach The Elia and Helga B Weinbach
Family Trust, dtd 12/23/80,
Separate Property Trust of Helga B W~inbach The Elia and Helga B Weinbach
Family Trust, dtd 12/23/80,
Separate Proper~ Trust of Helga B. Weinbach The Elia and Helga B Weinbach
Family Trust, dtd 12/23/80,
Separate Property Trust of Helga
B. Weinbach
NATURE OF A
INVESTMENT YOUR BUSINESS
D (if "other," POSITION
descdbe)*
INCLUDE YOUR
PRO RATA
SHARE OF
GROSS
INCOMETO
ENTITYKRUST*
LISTSINGLE
SOURCES OF
INCOME OF
$10,000OR MORE
LIST DATE INVESTMENT- REAL PROPERTY- NATURE OF
A INTEREST
OR ENTITYINAME, AND LOCATION OF VALUE*
DISPOSED D (If"other,"
BUSINESS ACTIVITY REALPROPERTY (mndd~2012)
descdbe)*
CA ST Econ Recovery
Oakland Calif SWR SER A
$10,001- Bond
$100,000
$10,001 o Bond
$100,000
$100,001 - Bond
$1,000,000
NO Orange CNTY CA CMMP $10,001 - Bond
$100,000
Univ CA AMBAC $100,001 - A Mutual Fund
$1,000,000
JPMorgan Strategic Income $100,001- A MutualFund
$1,000,000
Wells Fargo Advantage Ultr $10,001 - ETF
$100,000
Powershares DB Commodit $10,001 - ETF
$100,000
Health Care BElT INC
FPPC Form 700 (2011/2012) Sch: A-2x FPPC Toll-Free Helpline: 8661ASK-FPPC www.fppc.ca.gov
SCHEDULE A-2 Investments, Income, and Assets
of Business Entities/Trusts (Ownership Interest is 10% or Greater)
Name
Name
Address (Business Address Acceptable) "~l ~
Check one
¯ .~rust, go to 2 ~ Business Entity, complete the box, then go to 2
GENERAL DESCRIPTION OF BUSINESS ACTIVITY/~
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
[] $0 - $1.999
[] $2.ooo - $1o,ooo ! i 12 / I 12
[] $10,001 - $100.000 ACQUIRED DISPOSED
~’$100.001 - $1,000.000
[] Over $1,000,000
NATURE OF INVESTMENT
[] Partnership [] Sole Proprietorsh p r-7,,
YOUR BUS,NESS POS,T,ON Other
[] $0- $499
[] $500 - $1,000
[] $1,001 - $10,000
[] $10,001 - Sl00,000
~ OVER $100,000
~i None
V
Check one box:
~ INVESTMENT ~ REAL PROPERTY
Name o~ Business Entity, if Investment, or Assessor’s Parcel Number or Street Add-~ss el Real Property
Description of Business Activity o~r
C~ or Other Precise Location of Real Property
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
[] $2,ooo- $1o.ooo [~’$10,OOl - $10o.00o / /. 12 ~ .j 12
[]$100,001 - $1,000,000 ACQUIRED DISPOSED
[] Over $1,000,000
NATURE OF INTEREST
~"Property Ownership/Deed of Trust [] Stock [] Partnership
[] Leasehold [] Other _~_1~ ~,~.r~~ Yrs. remaining
[] Check box if additional schedules reporting investments or real oroperty are a~ached
Address (~usiness A~dress Acceptable)
Check o.~e
~..~rust, go to 2 ~ Business Enter},, complete the box, then go to 2
GENERAL DESCRIPTION OF BUSINESS ACTIVITY
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
[--] $0 - $1,999
[] s2,ooo - S!o,ooo f L 1 2 __1 1 12
.~ $1o,001 - $1oo,ooo ACQUIRED DISPOSED
$I00,00i - $1,000,000
[] Over $1,000,000
NATURE OF INVESTMENT [] Partnership ~ Sole Proprietorship
YOUR BUSINESS POSITION
r750- $499
[] $500 - $1,000
[] $1,001 - $10,000
~ $10,001 - $100.000
h~ OVER $100,000
--INone
Check one box:
~NVESTMENT ~ REAL PROPERTY
~--~Tf ~ t!~--~- Name of Business Entity, if Investment, or Assessor’s Parcel Number or Street Add-~ss of Real PropeEy
Description of Business Activity o_r
City o[ Other Precise Location of Real Property
IF APPLICABLE, LIST DATE:
/ / 12 __j.__L12 ACQUIRED DISPOSED
FAIR MARKET VALUE
~ 2,000 - $10.000
10.001 - $100,000
[] $100,001 - $1,000,000
[] Over $1,000.000
NATURE OF INTEREST
,~ Prope~y Ownership;Deed of Trust [] Stock [-~Pa~nership
[] Leasehold Yrs. remaining
[] Check box ~ additional schedules reporting investments or real property are attached
Comments: FPPC Form 700 (201212013) Sch. A-2
FPPC Advice Email: advice@fppc,ca.gov
FPPC Toll-Free Helpline: 866/275-3772 www.fppc,ca.gov
SCHEDULE A-2 Investments, Income, and Assets
of Business Entities/Trusts (Ownership Interest is 10% or Greater)
Name
Address (Business Address Acceptable) ~ ~.~ ~A~O~21~
Chec~.~e ~ Trust, go to 2 [] Business Entity, complete the box, then go to 2
FAIR MARKET VALUE
[] $0 - $1,999
i[] $2,000-$1o,ooo i!]~’$1o,ool - $1oo,ooo
I E~ $1oo ooi - $i,ooo,ooo [] Over $1,000,000
IF APPLICABLE, LIST DATE:
NATURE OF INVESTMENT
t /. 12 .___j ! 12 ACQUIRED DISPOSED
C~artnership [] Sole Proprietorship []
YOUR BUSINESS POSITION ~l~-,/I ~
[] so - $4~9 - $ioo,ooo [] $500- $1.000 [] OVER $100,000 [] $1,001 - $10,000
[] None
Check one box,"
[~NVESTMENT
Other
Name of Business Entity, if Investment, or AssessorIs Parcel Number or Street Address of Real Property
Description of Business Activity or City or Other Precise Location of Real Property
Nar~ff~
/~ddres~ (Business Address Acceptable)
Check one
~ Trust, go to 2 [] Business Entity, complete the box, then go to 2
FAIR MARKET VALUE
[] $0 - $1,999
[] $2,000 - $10,000
[] $10,001 - $!00,000
~ $100,001 - $1,000,000
Over $1,000,000
IF APPLICABLE, LIST DATE:
__J.__l. 12 !__1 12
ACQUIRED DISPOSED
NATUREOFINVESTMENT d ~ C [] Partnership [] Sole Proprietorship
Other
YOU R BUSIN ESS POSitiON N~-~ ~-’~
[] $o - $499
[] $500 - $i,0oo [~$1,001 - $10,000
$100,000
[] OVER $100,000
-1 None
Check one box:
J~NVESTMENT [] REAL PROPERTY
Name or Business Enlity, if Investment, or Assessor’s Parcel Number or Street Address of Real Property
Description of Business Activity o._E City or Other Precise Location of Real Property
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
[] $2,000 - $1o,ooo
1~$1o,ool. $1oo,ooo / / 12 , L / 12
$1oo,ool - $1,ooo,ooo ACQUIRED DISPOSED
[] Over $1,000,000
NATURE OF INTEREST
[] Property Ownership/Deed of Trust [] Stock [] Partnership
[] Leasehold [] Other Yrs. remaining
[] Check box if additional schedules reporting investments or real property are altached
FAIR MARKET VALUE IF APPLICABLE, LIST DATE
[] $2,000 I $10,000
[] $1o,ool. $1oo,ooo __/ / 12 / /. 12
~’$1oo,ool - $1,ooo,ooo ACQUIRED DISPOSED
[] Over $1,000,000
NATURE OF INTEREST
[] Property Ownership/Deed of Trust [] Stock [] Partnership
[] Leasehold [] Other Yrs. remaining
[] Check box if additional schedules reporting investments or real property are allached
Comments: FPPC Form 700 (201212013) Sch. A-2
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 wwwXppc.ca.gov
SCHEDULE A-2 Investments, Income, and Assets
of Business Entities/Trusts (Ownership Interest is 10% or Greater)
~rusL go to 2 ~ Business Entity, complete the box, then go to 2
GENERAL DESCRIPTION OF BUSI~ESS ACTIVITY
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
] $0 - $1.999
~.$2,ooo ~ $1o,ooo / ./. 12
] $10,001 :$100,000 ACQUIRED
~$100,001 - $1,000,000
__! / 12 DISPOSED
Over $1,000,000
NATURE OF INVESTMENT
~[~’Partnership [] Sole Proprietorship [] Other
YOUR BUSINESS POSITION ~’~~~’~"
Name
.
Name
Address (Business Address Acceptable> ~ ~~ C4. ~/~.~
Check one
~(b#t, go to 2 ~ Business E~tity, complete the box. then go to 2
GENERAL ..... DESCRIPTION OF BUSINESS ACTIVITY ~
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
[~ $0- $1,999 $2,od& - sic.coo __I / 12 __/ 11 12 [] $10.p0i - $100,000 ¯ACQUIRED DISPOSED
[] $100,001 -$i,000,000
[]Over $1,000,090
NATURE OF INVESTMENT
[] Partnership [] Sole Proprietorship [] Other
Y(JUR BUSINESS’POSITION - 5.~., ;.
[] $0 -$499
[] $5oo: ~ooo [] $t.001 -$t0,000.
[] Nohe
[] $500 - $1.ooo
$1o ooo
[] OVER $100,000
[] No~e ’1
Check one box." ..... "
J~INV~STM~_NT [] REAL PROPERTY
Name of Business Enlily, if Investment. or Assessor s Parcel Number or Street Address of Real Property
Description o[ Business Activity or Cily or Other Precise _ocation or Real Pr.gperiy
FAIR MARKET VALUE IF APPLICABLE LIST DATE:
Check*ohe box:
1 ~ INVESTMENT ~ REAL PROPERTY
Name of Business Entity, if nvestmenl or . Assessor’s Parcel Number or Street Address of Real ProBeYty
[] $2.000 - $10.000
[] $10,001 --$100.000 / /,12 / .-/ 12. ~ $100.001 - $1.0OO,000 ACQUIRED DISPOSED
[] Over $1.000.000
NATLRE OF INTEREST
[] Property O~ynershiplDeed of Trust [] ~tock [] Partnership
[] Leasehold [] Other Yrs. remaining
Description of BuIsiness Activity or City or Other P’r~ci~e Location of Real Property
FAIR MARKET ~ALUE IF APPLICABLE LIST DATE:
~1~ s2.ooo - slo.ooo $10.~301 - SlO0.O00 " ./ Z 12 __1 !. 12
~r.~ SlO0,001 ’- $1,0~0.0(~0 ACQUIRED DISPOSED
Over $1 000,000
[] Check box if addiliohal schedules reporting investments or real property a~e attached
NATURE OF INTEREST
[] Property Owflership/Deed of Trust [] Stock [] Parlnershio
[]Leasehold ~ Other Yrs remaining
[] Check box if additional schedules reporting investments o~ real property are attached
Comments: FPPC Form 700 (2012/2013) Sch. A-2
FPPC Advice Email: [email protected]
FPPC Toll-Free Helpiine: 866/275-3772 v,~Nw.fppc.ca.gov
SCHEDULE B Interests in Real PropeF&y
(Including Rental Income)
Name
CITY _
FAIR MARKET VALUE
[] $2,000 - $10,000 12 [] $10,001 - $100,000 /
ACQUIRED [] $100,001 - $1,000,000
,~ Over $1,000,000
NATURE OF INTEREST
[~j~OwnershiplDeed of Trust [] Easement
IF APPLICABLE, LIST DATE:
/___/12 DISPOSED
[] Leasehold [] Yrs, remaining Other
IF RENTAL PROPERTY, GROSS INCOME RECEIVED
[] $0 - $499 [] $500 - $1,000 [] $I,001 - $I0,000
~j~$1o,ool - $1oo,ooo D OVER $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.
[] N
ASSESSOR’S PARCEL NUMBER OR STREET ADDRESS
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
[] $2,000 - $1o,ooo
F-]. $1o,ool - $1oo,ooo / / 12 / /. 12 [] $100,001 - $1,000,000 ACQUIRED DISPOSED
[] Over $1,000,000
NATURE OF INTEREST
[~wnership/Deed of Trust ] Easement
[] Leasehold [] Yrs. remaining Other
IF RENTAL PROPERTY, GROSS INCOME RECEIVED
,~"$0 - $499 [] $500- $1,000 [] $1,001 - $10,000
[] $10,001 - $100,000 [--] OVER $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*
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF LENDER
INTEREST RATE TERM (Months/Years)
% [] None
HIGHEST BALANCE DURING REPORTING PERIOD
[] $500 - $1,ooo [] $1,OOl - $1o,ooo
[] $10,001 - $100,000 [] OVER $100,000
[] Guarantor, if applicable
NAME OF LENDER*
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF LENDER
INTEREST RATE TERM (Months/Years)
.% [] None
HIGHEST BALANCE DURING REPORTING PERIOD
[] $500 - $1,000 [] $1,001 - $10,000
[] $10,001 - $100,000 [] OVER $100,000
[] Guarantor, if applicable
Comments:
FPPC Form 700 (2012/2013) Sch. B FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 vwvw, fppc.ca,gov
SCHEDULE C Income, Loans, & Business
Positions (Other than Gifts and Travel Payments)
Name
BUSINESS ACTIVITY, IF ANY, OF SOURCE
YOUR BUSINESS POSITION
GROSS INCOME RECEIVED
[] $5oo- $1,ooo [] $1,oo7 - $1o,ooo
~$10,OO1 - $100,0OO [] OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
[] Salary [] Spouse’s or registered domestic partner’s income
[] Loan repayment [] Partnership
[] Sale of (Real property, car, boat, etc.)
[] Commission or [] Rental Income, list each source of $10,000 or more
[] Other (Descdbe)
NAME OF SOURCE OFINCOME
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
YOUR BUSINESS POSITION
GROSS INCOME RECEIVED
[] $500- $1,000 [] $1,001 - $10,000
[] S10,001 - $100,000 [] OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
[] Salary [] Spouse’s or registered domestic partner’s income
[] Loan repayment [] Partnership
[] Sale of (Real property, car, boat, etc.)
[] Commission or [] Rental Income, list each source of $10,000 or more
[] Other (Desc#be)
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 TERM (Months/Years)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF LENDER
% [] None
SECURITY FOR LOAN
[] None [] Personal residence
HIGHEST BALANCE DURING REPORTING PERIOD
[] $500 - sl.ooo
[] $1,OOl - $I0,000
[] $1o,ool - $1oo,ooo
[] OVER $I00,000
[] Real Property
-"]Guarantor
[] Other
Street address
City
(Describe)
Comments:
FPPC Form 700 (201212013) Sch. C FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc,ca.gov
SCHEDULE D Income - Gifts
Name
¯ NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DAT U DESCRIPTION OF GIFT(S)
FIPF I !
I
~ NAME OF SOURCE (Not an Ac~nym)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S)
/ !
/ /
/ /
~ NAME OF SOURCE (Not an Acmnym)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S)
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S)
]. ].__
L__J.
¯ NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY. OF SOURCE
DATE (mm/dd!yy) VALUE
L 1_
L L $
__J / $
l / $
__l / $
¯ NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
DATE (mm!ddiyy) VALUE
__/ /.__ $
__/_ /___ $
__/_ /___ $
DESCRIPTION OF GIFT(S)
DESCRIPTION OF GIFT(S)
Comments:
FPPC Form 700 (2012/2013) Sch. D FPPC Advice Email: [email protected]
FPPC Toll-Free Helpline: 866/275-3772 v~rw.fppc.ca.gov
SCHEDULE E Income - Gifts
Travel Payments, Advances, and Reimbursements
Name
You must 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)
ADDRE~’(~B~siness Address Acceptable)
DATE(S): (If gift)
TYPE OF PAYMENT: (must check one) [] Gift [] Income
[] Made a Speech/Participated in a Panel
[] Other - Provide Description
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
CITY AND STATE
BUSINESS ACTIVITY, IF ANY, OF SOURCE [] 501 (c)(3)
DATE(S): /. Z / / AMT: $. (If gift)
TYPE OF PAYMENT: (must check one) [] Gift [] Income
[] Made a Speech/Participated in a Panel
[] Other - Provide Description
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
CITY AND STATE
BUSINESS ACTIVITY, IF ANY. OF SOURCE
DATE(S): __/_ J. AMT: $. (If gift)
[] Gift TYPE OF PAYMENT: (must check one)
[] Made a Speech/Participated in a Panel
[] Other - Provide Description
NAME OF SOURCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
CITY AND STATE
BUSINESS ACTIVITY, IF ANY, OF SOURCE
[] 5ol (c)(3)
[] Income
[] 501 (c)(3)
[] Income
DATE(S): I I. (If gift) I.__J.__ AMT:
TYPE OF PAYMENT: (must check one) [] Gift
[] Made a Speech/Participated in a Panel
[] Other - Provide Description
Comments:
FPPC Form 700 (2012/2013) Sch. E FPPC Advice Emaih [email protected]
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov