700 - fppc.ca.gov...See Reference Pamphlet, page 15, for more information on disclosing trusts. •...

Please type or print in ink.

700FAIR POLITICAL PRACTICES COMMISSION

CALIFORNIA FORM

A M E N D M E N T

Leaving Office: Date Left / / (Check one)

The period covered is January 1, 2015, through the date of leaving office.

The period covered is / / , through the date of leaving office.

Annual: The period covered is January 1, 2015, through December 31, 2015.

The period covered is / / , through December 31, 2015.

STATEMENT OF ECONOMIC INTERESTS

COVER PAGE

FPPC Form 700 (2015/2016)FPPC Advice Email: [email protected]

FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov

I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained herein and in any attached schedules is true and complete. I acknowledge this is a public document.

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)

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

State Judge or Court Commissioner (Statewide Jurisdiction)

Multi-County County of

City of Other

2. Jurisdiction of Office (Check at least one box)

Candidate: Election year and office sought, if different than Part 1:

Assuming Office: Date assumed / /

Date Initial Filing ReceivedOfficial Use Only

Agency Name (Do not use acronyms)

Division, Board, Department, District, if applicable Your Position

1. Office, Agency, or Court

NAME OF FILER (LAST) (FIRST) (MIDDLE)

MAILING ADDRESS STREET CITY STATE ZIP CODE

( )DAYTIME TELEPHONE NUMBER E-MAIL ADDRESS

(Business or Agency Address Recommended - Public Document)

Signature (File the originally signed statement with your filing official.)

5. Verification

► If filing for multiple positions, list below or on an attachment. (Do not use acronyms)

Agency: Position:

-or-

-or-

Schedules attached

Schedule A-1 - Investments – schedule attached Schedule A-2 - Investments – schedule attached Schedule B - Real Property – schedule attached

Schedule C - Income, Loans, & Business Positions – schedule attached Schedule D - Income – Gifts – schedule attached Schedule E - Income – Gifts – Travel Payments – schedule attached

None - No reportable interests on any schedule

4. Schedule Summary (must complete) ► Total number of pages including this cover page:

-or-

Enter your name, mailing address, and daytime telephone number in the spaces provided. Because the Form 700 is a public document, you may list your business/office address instead of your home address.

Part 1. Office, Agency, or Court• Enterthenameoftheofficesoughtorheld,ortheagency

or court. Consultants must enter the public agency name ratherthantheirprivatefirm’sname.(Examples:StateAssembly;BoardofSupervisors;OfficeoftheMayor;DepartmentofFinance;HopeCountySuperiorCourt)

• Indicate the name of your division, board, or district, if applicable.(Examples:DivisionofWasteManagement;Board of Accountancy; District 45). Do not use acronyms.

• Enteryourpositiontitle.(Examples:Director;ChiefCounsel;CityCouncilMember;StaffServicesAnalyst)

• If you hold multiple positions (i.e., a city council member who also is a member of a county board or commission), youmayberequiredtofilestatementswitheachagency.Tosimplifyyourfilingobligations,youmaycompleteanexpandedstatement.

• To do this, enter the name of the other agency(ies) with whichyouarerequiredtofileandyourpositiontitle(s)inthe space provided. Do not use acronyms. 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 agency.Signeachcopywithanoriginalsignatureandfilewith each agency.

Ifyouassumeorleaveapositionafterafilingdeadline,youmustcompleteaseparatestatement.Forexample,acity council member who assumes a position with a county specialdistrictaftertheApril1annualfilingdeadlinemustfileaseparateassumingofficestatement.Insubsequentyears,thecitycouncilmembermayexpandhisorherannualfilingtoinclude both positions.

Example:ScottBakerisacitycouncilmemberfortheCityofLincolnandaboardmemberfortheCampFarWestIrrigationDistrict – a multi-county agency that covers Placer and Yubacounties.ScottwillcompleteoneForm700usingfulldisclosure (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.Beforesigningthestatement,Scottwillmakeacopyandsignbothstatements.OnestatementwillbefiledwithCityofLincolnandtheotherwillbefiledwithCampFarWestIrrigation District. Both will contain an original signature.

Part 2. Jurisdiction of Office• Checktheboxindicatingthejurisdictionofyouragency

and,ifapplicable,identifythejurisdiction.Judges,judicialcandidates, and court commissioners have statewide jurisdiction.AllotherfilersshouldreviewtheReferencePamphlet,page13,todeterminetheirjurisdiction.

• Ifyouragencyisamulti-countyoffice,listeachcountyinwhichyouragencyhasjurisdiction.

• Ifyouragencyisnotastateoffice,court,countyoffice,cityoffice,ormulti-countyoffice(e.g.,schooldistricts,specialdistrictsandJPAs),checkthe“other”boxandenterthecountyorcityinwhichtheagencyhasjurisdiction.

Example: ThisfilerisamemberofawaterdistrictboardwithjurisdictioninportionsofYubaandSutterCounties.

Part 3. Type of Statement

Checkatleastonebox.Theperiodcoveredbyastatementisdeterminedbythetypeofstatementyouarefiling.Ifyouarecompletinga2015 annual statement, do not change the pre-printeddatestoreflect2016. Your annual statement is used for reporting the previous year’s economic interests. EconomicinterestsforyourannualfilingcoveringJanuary1,2016,throughDecember 31, 2016,willbedisclosedonyourstatementfiledin2017. SeeReferencePamphlet,page4.

CombiningStatements:Certaintypesofstatementsmaybecombined.Forexample,ifyouleaveofficeafterJanuary1,butbeforethedeadlineforfilingyourannualstatement,youmaycombineyourannualandleavingofficestatements.Filebytheearliestdeadline.ConsultyourfilingofficerortheFPPC.

Part 4. Schedule Summary• CompletetheScheduleSummaryafteryouhavereviewed

each schedule to determine if you have reportable interests.

• Enter the total number of completed pages including the coverpageandeitherchecktheboxforeachscheduleyouuse to disclose interests; or if you have nothing to disclose onanyschedule,checkthe“Noreportableinterests”box. Please do not attach any blank schedules.

Part 5. VerificationCompletetheverificationbysigningthestatementandentering the date signed. All statements must have an original “wet”signatureorbedulyauthorizedbyyourfilingofficertofileelectronicallyunderGovernmentCodeSection87500.2.Instructions,examples,FAQs,andareferencepamphletareavailable to help answer your questions. When you sign your statement, you are stating, under penalty of perjury, that it is true and correct.Onlythefilerhasauthoritytosignthestatement.Anunsignedstatementisnotconsideredfiledandyoumaybesubjecttolatefilingpenalties.

InstructionsCover Page


FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.govInstructions – 1

State Judge or Court Commissioner (Statewide Jurisdiction)

Multi-County County of

City of Other

2. Jurisdiction of Office (Check at least one box)

Agency Name (Do not use acronyms)

Division, Board, Department, District, if applicable Your Position

1. Office, Agency, or Court

► If filing 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

Filer’s Verification

Print Name

Office, Agencyor Court

Statement Type 2015/2016Annual Assuming Leaving Annual Candidate (yr)

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.



Filer’s Signature

IFAPPLICABLE,LISTDATE:

/ / / / ACQUIRED DISPOSED









15 15 15 15

1515

1515

►NAMEOFBUSINESSENTITY

GENERALDESCRIPTIONOFTHISBUSINESS









Comments:

SCHEDULE A-1Investments

Stocks,Bonds,andOther Interests(Ownership Interest isLessThan10%)

Do not attach brokerage or financial statements.

FPPC Form 700 (2015/2016) Sch. A-1FPPC Advice Email: [email protected]


FAIRMARKETVALUE $2,000 -$10,000 $10,001 -$100,000 $100,001 -$1,000,000 Over$1,000,000





NATUREOF INVESTMENT Stock Other

(Describe) Partnership Income Receivedof$0 -$499

IncomeReceivedof$500orMore (Report on Schedule C)


(Describe) Partnership IncomeReceivedof$0 -$499






(Describe) Partnership Income Receivedof$0 -$499





1515


CALIFORNIA FORM

A M E N D M E N T

Instructions – Schedules A-1 and A-2Investments

“Investment”meansafinancialinterestinanybusinessentity (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 theprevioustwoyearsinyouragency’sjurisdictioninwhichyou, your spouse or registered domestic partner, or your dependentchildrenhadadirect,indirect,orbeneficialinteresttotaling$2,000ormoreatanytimeduringthereportingperiod.SeeReferencePamphlet,page13.

Reportable investments include:• Stocks,bonds,warrants,andoptions,includingthoseheld

in margin or brokerage accounts and managed investment funds(SeeReferencePamphlet,page13.)

• Soleproprietorships• Yourownbusinessoryourspouse’sorregistered

domesticpartner’sbusiness(SeeReferencePamphlet,page8,forthedefinitionof“businessentity.”)

• Yourspouse’sorregistereddomesticpartner’sinvestments even if they are legally separate property

• Partnerships(e.g.,alawfirmorfamilyfarm)• Investments in reportable business entities held in a

retirementaccount(SeeReferencePamphlet,page15.)• If you, your spouse or registered domestic partner,

anddependentchildrentogetherhada10%orgreaterownership interest in a business entity or trust (including a living trust), you must disclose investments held by the businessentityortrust.SeeReferencePamphlet,page15, for more information on disclosing trusts.

• Business trusts

You are not required to disclose:• Insurancepolicies,governmentbonds,diversifiedmutual

funds,certainfundssimilartodiversifiedmutualfunds(suchasexchangetradedfunds)andinvestmentsheldincertainretirementaccounts.SeeReferencePamphlet,page13,fordetailedinformation.(Regulation18237)

• Bank accounts, savings accounts, money market accounts andcertificatesofdeposits

• Insurance policies• Annuities• Commodities• Sharesinacreditunion• Governmentbonds(includingmunicipalbonds)• Retirement accounts invested in non-reportable interests

(e.g., insurance policies, mutual funds, or government bonds)(SeeReferencePamphlet,page15.)

• Governmentdefined-benefitpensionplans(suchasCalPERSandCalSTRSplans)

• Certaininterestsheldinablindtrust(SeeReferencePamphlet,page16.)

Use Schedule A-1toreportownershipoflessthan10%(e.g.,stock).ScheduleC(Income)mayalsoberequirediftheinvestmentisnotastockorcorporatebond.Seesecondexamplebelow.

Use Schedule A-2toreportownershipof10%orgreater(e.g., a sole proprietorship).

To Complete Schedule A-1:Donotattachbrokerageorfinancialstatements.

• 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).

• Checktheboxindicatingthehighestfairmarketvalueofyour investment during the reporting period. If you are filingacandidateoranassumingofficestatement,indicatethefairmarketvalueonthefilingdateorthedateyoutookoffice,respectively.

• Identify the nature of your investment (e.g., stocks, 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. Generally,thesedateswillnotapplyifyouarefilingacandidateoranassumingofficestatement.

Examples:JohnSmithholdsastateagencyposition.Hisconflictofinterestcoderequiresfulldisclosureofinvestments.Johnmustdisclosehisstockholdingsof$2,000ormoreinanycompany 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.

SusanJonesisacitycouncilmember.Shehasa4%interest,worth$5,000,inalimitedpartnershiplocatedinthecity.SusanmustdisclosethepartnershiponScheduleA-1andincomeof$500ormorereceivedfromthepartnershiponScheduleC.

Reminders• Doyouknowyouragency’sjurisdiction?• Did you hold investments at any time during the period coveredbythisstatement?

• Codefilers–yourdisclosurecategoriesmayonlyrequiredisclosureofspecificinvestments.




CALIFORNIA FORM

A M E N D M E N T

►3. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF INCOME OF $10,000 OR MORE (Attach a separate sheet if necessary.)





1515 15

SCHEDULE A-2Investments, Income, and Assets

of Business Entities/Trusts(Ownership Interest is10%orGreater)

Name

Address (Business Address Acceptable)

FAIRMARKETVALUE $0-$1,999 $2,000 -$10,000 $10,001 -$100,000 $100,001 -$1,000,000 Over$1,000,000


INVESTMENT REALPROPERTY

NameofBusinessEntity, if Investment,or Assessor’sParcelNumberorStreetAddressofRealProperty

Description of Business Activity orCityorOtherPreciseLocationofRealProperty

►4. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD OR LEASED BY THE BUSINESS ENTITY OR TRUST

Check one Trust, go to 2 Business Entity, complete the box, then go to 2

►2. IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA SHARE OF THE GROSS INCOME TO THE ENTITY/TRUST)

Check one box:

YOURBUSINESSPOSITION

FPPC Form 700 (2015/2016) Sch. A-2FPPC Advice Email: [email protected]



$0-$499 $500-$1,000 $1,001 -$10,000

$10,001 -$100,000 OVER$100,000

►1. BUSINESS ENTITY OR TRUST

NATUREOF INTEREST PropertyOwnership/DeedofTrust Stock Partnership

Leasehold Other

Checkbox ifadditionalschedules reporting investmentsor realproperty are attached

Yrs. remaining

15

Other

NATUREOF INVESTMENT Partnership SoleProprietorship

None or Names listedbelowComments:


Print Name

Office, Agency or Court

Statement Type 2015/2016Annual Annual Assuming Leaving Candidate (yr)



Date Signed Filer’s Signature (month, day, year)

Instructions – Schedule A-2Investments, Income, and Assets of Business Entities/Trusts



UseScheduleA-2toreportinvestmentsinabusinessentity (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%orgreaterinterest,totaling$2,000ormore,duringthereporting period and which is located in, doing business in, planning to do business in, or which has done business during theprevioustwoyearsinyouragency’sjurisdiction.SeeReference Pamphlet, page 13. A trust located outside your agency’sjurisdictionisreportableifitholdsassetsthatarelocatedinordoingbusinessinthejurisdiction.Donotreportatrustthatcontainsnon-reportableinterests.Forexample,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.

AlsoreportonScheduleA-2investmentsandrealpropertyheld by that entity or trust if your pro rata share of the investmentorrealpropertyinterestwas$2,000ormoreduring the reporting period.

To Complete Schedule A-2:Part 1. Disclose the name and address of the business entity or trust. If you are reporting an interest in a business entity, check“BusinessEntity”andcompletetheboxasfollows:

• Provide a general description of the business activity of the entity.

• Checktheboxindicatingthehighestfairmarketvalueofyour investment during the reporting period.

• If you initially acquired or entirely disposed of this interest during the reporting period, enter the date acquired or disposed.

• Identify the nature of your investment.• Disclosethejobtitleorbusinesspositionyouheldwiththe

entity,ifany(i.e.,ifyouwereadirector,officer,partner,trustee, employee, or held any position of management). A business position held by your spouse is not reportable.

Part 2. Checktheboxindicatingyour 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 propertyinterestinyourspouse’sorregistereddomesticpartner’sshare.Gross income is the total amount of income beforedeductingexpenses,losses,ortaxes.

Part 3. 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 agency’sjurisdiction,asfollows:

• Disclose each source of income and outstanding loan to the business entity or trustidentifiedinPart1ifyour pro rata share of the gross income (including your communitypropertyinterestinyourspouse’sorregistereddomesticpartner’sshare)tothebusinessentityortrustfromthatsourcewas$10,000ormoreduringthereporting

period.SeeReferencePamphlet,page11,forexamples.Income from governmental sources may be reportable ifnotconsideredsalary.SeeRegulation18232.Loansfromcommerciallendinginstitutionsmadeinthelender’sregular course of business on terms available to members ofthepublicwithoutregardtoyourofficialstatusarenotreportable.

• Disclose each individual or entity that was a source ofcommissionincomeof$10,000ormoreduringthereportingperiodthroughthebusinessentityidentifiedinPart1.SeeReferencePamphlet,page8,foranexplanationofcommissionincome.

You may be required to disclose sources of income located outsideyourjurisdiction.Forexample,youmayhaveaclientwhoresidesoutsideyourjurisdictionwhodoesbusinessonaregularbasiswithyou.Suchaclient,ifareportablesourceof$10,000ormore,mustbedisclosed.

Mark“None”ifyoudonothaveanyreportable$10,000sourcesofincometodisclose.Usingphrasessuchas“variousclients”or“notdisclosingsourcespursuanttoattorney-clientprivilege”maytriggerarequestforanamendmenttoyourstatement.SeeReference Pamphlet, page14,fordetailsaboutrequestinganexemptionfromdisclosing privileged information.

Part 4. Report any investments or interests in real property held or leased by the entity or trustidentifiedinPart1ifyourproratashareoftheinterestheldwas$2,000ormoreduringthe reporting period. Attach additional schedules or use FPPC’sForm700Excelspreadsheetifneeded.

• Checktheapplicableboxidentifyingtheinterestheldasreal property or an investment.

• If investment, provide the name and description of the business entity.

• If real property, report the precise location (e.g., an assessor’sparcelnumberoraddress).

• Checktheboxindicatingthehighestfairmarketvalueof your interest in the real property or investment during the reporting period. (Report the fair market value of the portionofyourresidenceclaimedasataxdeductionifyouareutilizingyourresidenceforbusinesspurposes.)

• Identify the nature of your interest.• 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.


CALIFORNIA FORM

A M E N D M E N T





15 1515 15

SCHEDULE BInterests in Real Property

(Including Rental Income)

►ASSESSOR’SPARCELNUMBERORSTREETADDRESS

►ASSESSOR’SPARCELNUMBERORSTREETADDRESS

CITY CITY

INTERESTRATE TERM(Months/Years)

% None

SOURCESOFRENTAL INCOME: Ifyouowna10%orgreaterinterest, list the name of each tenant that is a single source of incomeof$10,000ormore.

SOURCESOFRENTAL INCOME: Ifyouowna10%orgreaterinterest, list the name of each tenant that is a single source of incomeof$10,000ormore.

NATUREOF INTEREST

Ownership/DeedofTrust Easement

Leasehold Yrs. remaining Other

NATUREOF INTEREST

Ownership/DeedofTrust Easement

Leasehold Yrs. remaining Other

Comments:



IFRENTALPROPERTY,GROSSINCOMERECEIVED

OVER$100,000

$500-$1,000 $0-$499 $1,001 -$10,000

$10,001 -$100,000

IFRENTALPROPERTY,GROSSINCOMERECEIVED

OVER$100,000

$500-$1,000 $0-$499 $1,001 -$10,000

$10,001 -$100,000

HIGHESTBALANCEDURINGREPORTINGPERIOD

Guarantor, ifapplicable

OVER$100,000

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

$10,001 -$100,000

FPPC Form 700 (2015/2016) Sch. BFPPC Advice Email: [email protected]


NAMEOFLENDER*

ADDRESS (Business Address Acceptable)

BUSINESSACTIVITY, IFANY,OFLENDER

* Youarenotrequiredtoreportloansfromcommerciallendinginstitutionsmadeinthelender’sregularcourseofbusinessontermsavailabletomembersofthepublicwithoutregardtoyourofficialstatus.Personalloansandloansreceivednotinalender’sregularcourseofbusinessmustbedisclosedasfollows:

None None


Print Name






Filer’s Signature

tenantwas$10,000ormoreduringthereportingperiod.Ifyoureceivedatotalof$10,000ormorefromtwoormoretenants acting in concert (in most cases, this will apply to married couples), disclose the name of each tenant. Otherwise,mark“None.”

• Loansfromaprivatelenderthattotal$500ormoreandare secured by real property may be reportable. 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 are not reportable.

Whenreportingaloan: - Provide the name and address of the lender. - Describethelender’sbusinessactivity. - 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.

- Checktheboxindicatingthehighestbalanceoftheloan during the reporting period.

- Identify a guarantor, if applicable.

If you have more than one reportable loan on a single piece of realproperty,reporttheadditionalloan(s)onScheduleC.

Example: JoeNelsonisacityplanningcommissioner.Joereceivedrentalincomeof$12,000during the reporting period from a single tenant who rentedpropertyJoeownedinthecity’sjurisdiction.IfJoehadreceivedthe$12,000from two or more tenants, the tenants’nameswouldnotberequired as long as no single tenantpaid$10,000ormore.A married couple would be considered a single tenant.

Instructions – Schedule BInterests in Real Property

Reminders• IncomeandloansalreadyreportedonScheduleBarenotalsorequiredtobereportedonScheduleC.

• RealpropertyalreadyreportedonScheduleA-2,Part4isnotalsorequiredtobereportedonScheduleB.

•Codefilers– do your disclosure categories require disclosureofrealproperty?



Reportinterestsinrealpropertylocatedinyouragency’sjurisdictioninwhichyou,yourspouseorregistereddomesticpartner, or your dependent children had a direct, indirect, or beneficialinteresttotaling$2,000ormoreanytimeduringthereportingperiod.SeeReferencePamphlet,page13.

Interests in real property include:• Anownershipinterest(includingabeneficialownership

interest)• A deed of trust, easement, or option to acquire property• Aleaseholdinterest(SeeReferencePamphlet,page14.)• A mining lease• An interest in real property held in a retirement account

(SeeReferencePamphlet,page15.)• An interest in real property held by a business entity or

trust in which you, your spouse or registered domestic partner,andyourdependentchildrentogetherhada10%orgreaterownershipinterest(ReportonScheduleA-2.)

• Yourspouse’sorregistereddomesticpartner’sinterestsinreal property that are legally held separately by him or her

You are not required to report:• A residence, such as a home or vacation cabin, used

exclusivelyasapersonalresidence(However,aresidencein which you rent out a room or for which you claim a business deduction may be reportable. If reportable, reportthefairmarketvalueoftheportionclaimedasataxdeduction.)Please note: A non-reportable residence can still be groundsforaconflictofinterestandmaybedisqualifying.

• Interestsinrealpropertyheldthroughablindtrust(SeeReferencePamphlet,page16,forexceptions.)

To Complete Schedule B:• Reportthepreciselocation(e.g.,anassessor’sparcel

number or address) of the real property.• Checktheboxindicatingthefairmarketvalueofyour

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.

• Identify the nature of your interest. If it is a leasehold, disclose the number of years remaining on the lease.

• Ifyoureceivedrentalincome,checktheboxindicatingthegross amount you received.

• Ifyouhada10%orgreaterinterestinrealpropertyandreceived rental income, list the name of the source(s) if your pro rata share of the gross income from any single

ASSESSOR’S PARCEL NUMBER OR STREET ADDRESS

Easement Ownership/Deed of Trust

IF RENTAL PROPERTY, GROSS INCOME RECEIVED

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 $10,00 or more.

Leasehold

NAME OF LENDER

*


BUSINESS ACTIVITY, IF ANY, OF LENDER

INTEREST RATE

NONE

NONE

TERM (Month/Years)

OtherYrs. remaining

NATURE OF INTEREST

FAIR MARKET VALUE IF APPLICABLE, LIST DATE:

___/___/___ ___/___/___ ACQUIRED DISPOSED

15 15

Over $1,000,000$100,001-$1,000,000$10,001-$100,000$2,000-$10,000

OVER $100,000

OVER $100,000

$10,001 - $100,000

$10,001 - $100,000

Guarantor, if applicable

HIGHEST BALANCE DURING REPORTING PERIOD

$1,001 - $10,000

$1,001 - $10,000

$500 - $1,000

$500 - $1,000

$0 - $499

City

4600 24th Street

Sacramento

Henry Wells

8 15 Years

Sophia Petroillo

2121 Blue Sky Parkway, Sacramento

Restaurant Owner

x

x

x

x

%


CALIFORNIA FORM

A M E N D M E N T

(Real property, car, boat, etc.) (Real property, car, boat, etc.)

SCHEDULE CIncome, Loans, & Business

Positions(Other thanGiftsandTravelPayments)

► 2. LOANS RECEIVED OR OUTSTANDING DURING THE REPORTING PERIOD

CONSIDERATIONFORWHICHINCOMEWASRECEIVED Salary Spouse’sor registereddomesticpartner’s income

(Forself-employeduseScheduleA-2.)

Partnership (Less than10%ownership.For10%orgreateruse ScheduleA-2.)

Saleof

Other

CONSIDERATIONFORWHICHINCOMEWASRECEIVED Salary Spouse’sor registereddomesticpartner’s income

(Forself-employeduseScheduleA-2.)

Partnership (Less than10%ownership.For10%orgreateruse ScheduleA-2.)

Saleof

Other

(Describe) (Describe)

(Describe) (Describe)

Rental Income, list each source of $10,000 or more Rental Income, list each source of $10,000 or moreCommission or Commission or

Loanrepayment Loan repayment

NAMEOFLENDER*


BUSINESSACTIVITY, IFANY,OFLENDER

INTERESTRATE TERM(Months/Years)

% None

HIGHESTBALANCEDURINGREPORTINGPERIOD

$500-$1,000

$1,001 -$10,000

$10,001 -$100,000

OVER$100,000

SECURITYFORLOAN

None Personal residence

Real Property

Guarantor

Other

Street address

City

(Describe)

Filer’s VerificationPrint Name Office, Agency or Court

Statement Type 2015/2016Annual Annual Assuming Leaving Candidate (yr)

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 Filer’s Signature (month, day, year)

GROSSINCOMERECEIVED

OVER$100,000 $500-$1,000 $1,001 -$10,000 $10,001 -$100,000

► 1. INCOME RECEIVED NAMEOFSOURCEOF INCOME


BUSINESSACTIVITY, IFANY,OFSOURCE


► 1. INCOME RECEIVED NAMEOFSOURCEOF INCOME




GROSSINCOMERECEIVED

OVER$100,000 $500-$1,000 $1,001 -$10,000 $10,001 -$100,000

FPPC Form 700 (2015/2016) Sch. CFPPC Advice Email: [email protected]


Comments:

* You are not required to report loans from commercial lending institutions, or any indebtedness created as part of a retail installment or creditcardtransaction,madeinthelender’sregularcourseofbusinessontermsavailabletomembersofthepublicwithoutregardtoyourofficialstatus.Personalloansandloansreceivednotinalender’sregularcourseofbusinessmustbedisclosedasfollows:

Instructions – Schedule CIncome, Loans, & Business Positions

(Income Other Than Gifts and Travel Payments)



Reporting Income:Reportthesourceandamountofgrossincomeof$500ormoreyoureceivedduringthereportingperiod.Grossincomeisthetotalamountofincomebeforedeductingexpenses,losses,ortaxesandincludesloansotherthanloansfromacommerciallendinginstitution.SeeReferencePamphlet,page 11. You must also report the source of income to your spouse or registered domestic partner if your community propertysharewas$500ormoreduringthereportingperiod.

A source of 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 agency’sjurisdiction.SeeReferencePamphlet,page13,formoreinformationaboutdoingbusinessinthejurisdiction.Reportable sources of income may be further limited by yourdisclosurecategorylocatedinyouragency’sconflictofinterest code.

Reporting Business Positions:Youmustreportyourjobtitlewitheachreportablebusinessentity even if you received no income during the reporting period.Usethecommentssectiontoindicatethatnoincomewas received.

Commonly reportable income and loans include:• Salary/wages,perdiem,andreimbursementforexpenses

including travel payments provided by your employer• Communitypropertyinterest(50%)inyourspouse’s

orregistereddomesticpartner’sincome-report the employer’s name and all other required information

• Income from investment interests, such as partnerships, reportedonScheduleA-1

• Commission income not required to be reported on ScheduleA-2(SeeReferencePamphlet,page8.)

• Grossincomefromanysale,includingthesaleofahouseor car (Report your pro rata share of the total sale price.)

• RentalincomenotrequiredtobereportedonScheduleB• Prizesorawardsnotdisclosedasgifts• Payments received on loans you made to others • Anhonorariumreceivedpriortobecomingapublicofficial

(SeeReferencePamphlet,page10,concerningyourabilityto receive future honoraria.)

• Incentivecompensation(SeeReferencePamphlet,page12.)

You are not required to report:• Salary,reimbursementforexpensesorperdiem,or

socialsecurity,disability,orothersimilarbenefitpaymentsreceived by you or your spouse or registered domestic partner from a federal, state, or local government agency.

• Stockdividendsandincomefromthesaleofstockunlessthesourcecanbeidentified.

• IncomefromaPERSretirementaccount.

See Reference Pamphlet, page 11, for more exceptions to income reporting.

To Complete Schedule C:Part 1. Income Received/Business Position Disclosure• 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.

• Checktheboxindicatingtheamountofgrossincomereceived.

• Identify the consideration for which the income was received.

• Forincomefromcommissionsales,checktheboxindicating the gross income received and list the name of eachsourceofcommissionincomeof$10,000ormore.SeeReferencePamphlet,page8.Note: If you receive commission income on a regular basis or have an ownership interest of 10% or more, you must disclose the business entity and the income on Schedule A-2.

• Disclosethejobtitleorbusinessposition,ifany,thatyouheld with the business entity, even if you did not receive income during the reporting period.

Part 2. Loans Received or Outstanding During the Reporting Period• Provide the name and address of the lender.• Provide a general description of the business activity if the

lender is a business entity.• Checktheboxindicatingthehighestbalanceoftheloan

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.

• Identify the security, if any, for the loan.

Reminders• Codefilers–yourdisclosurecategoriesmaynotrequire

disclosure of all sources of income.• If you or your spouse or registered domestic partner are

self-employed,reportthebusinessentityonScheduleA-2.• DonotdiscloseonScheduleCincome,loans,orbusiness

positionsalreadyreportedonSchedulesA-2orB.


CALIFORNIA FORM

A M E N D M E N T

SCHEDULE DIncome – Gifts

Comments:

FPPC Form 700 (2015/2016) Sch. DFPPC Advice Email: [email protected]


►NAMEOFSOURCE (Not an Acronym)



DATE (mm/dd/yy) VALUE DESCRIPTIONOFGIFT(S)

/ / $

/ / $

/ / $





/ / $

/ / $

/ / $





/ / $

/ / $

/ / $





/ / $

/ / $

/ / $





/ / $

/ / $

/ / $


Print Name






Filer’s Signature

Instructions – Schedule DIncome – Gifts

Reminders• Giftsfromasinglesourcearesubjecttoa$460limit.SeeReferencePamphlet,page10.

•Codefilers– you only need to report gifts from reportable sources.

Gift Tracking Mobile Application

•FPPC has created a gift tracking app for mobile devicesthathelpsfilerstrackgiftsandprovidesaquickand easy way to upload the information to the Form 700.VisitFPPC’swebsitetodownloadtheapp.



A gift is anything of value for which you have not provided equal or greater consideration to the donor. A gift is reportableifitsfairmarketvalueis$50ormore.Inaddition,multiplegiftstotaling$50ormorereceivedduringthereporting period from a single source must be reported.

It is the acceptance of a gift, not the ultimate use to which it is put,thatimposesyourreportingobligation.Exceptasnotedbelow, you must report a gift even if you never used it or if you gave it away to another person.

Iftheexactamountofagiftisunknown,youmustmakeagoodfaithestimateoftheitem’sfairmarketvalue.Listingthevalueofagiftas“over$50”or“valueunknown”isnotadequate disclosure. In addition, if you received a gift through an intermediary, you must disclose the name, address, and business activity of both the donor and the intermediary. You mayindicateanintermediaryeitherinthe“source”fieldafterthenameorinthe“comments”sectionatthebottomofScheduleD.

Commonly reportable gifts include:• Tickets/passestosportingorentertainmentevents• Tickets/passestoamusementparks• Parkingpassesnotusedforofficialagencybusiness• Food, beverages, and accommodations, including those

provided in direct connection with your attendance at a convention, conference, meeting, social event, meal, or like gathering

• Rebates/discountsnotmadeintheregularcourseofbusinesstomembersofthepublicwithoutregardtoofficialstatus

• Weddinggifts(SeeReferencePamphlet,page16)• Anhonorariumreceivedpriortoassumingoffice(Youmay

reportanhonorariumasincomeonScheduleC,ratherthanasagiftonScheduleD,ifyouprovidedservicesofequalorgreatervaluethanthepaymentreceived.SeeReference Pamphlet,page10,regardingyourabilitytoreceive future honoraria.)

• Transportationandlodging(SeeScheduleE.)• Forgiveness of a loan received by you

You are not required to disclose:• Giftsthatwerenotusedandthat,within30daysafter

receipt, were returned to the donor or delivered to a charitableorganizationorgovernmentagencywithout

beingclaimedbyyouasacharitablecontributionfortaxpurposes

• Giftsfromyourspouseorregistereddomesticpartner,child, parent, grandparent, grandchild, brother, sister, and certainotherfamlymembers(SeeRegulation18942foracompletelist.).Theexceptiondoesnotapplyifthedonorwas acting as an agent or intermediary for a reportable source who was the true donor.

• Giftsofsimilarvalueexchangedbetweenyouandanindividual, other than a lobbyist registered to lobby your state agency, on holidays, birthdays, or similar occasions

• Giftsofinformationalmaterialprovidedtoassistyouintheperformanceofyourofficialduties(e.g.,books,pamphlets,reports, calendars, periodicals, or educational seminars)

• A monetary bequest or inheritance (However, inherited investments or real property may be reportable on other schedules.)

• Personalizedplaquesortrophieswithanindividualvalueoflessthan$250

• Campaign contributions• Uptotwotickets,foryourownuse,toattendafundraiser

for a campaign committee or candidate, or to a fundraiser foranorganizationexemptfromtaxationunderSection501(c)(3)oftheInternalRevenueCode.Theticketmustbereceivedfromtheorganizationorcommitteeholdingthefundraiser.

• Giftsgiventomembersofyourimmediatefamilyifthesource has an established relationship with the family member and there is no evidence to suggest the donor had apurposetoinfluenceyou.(SeeRegulation18943.)

• Free admission, food, and nominal items (such as a pen, pencil, mouse pad, note pad or similar item) available to allattendees,attheeventatwhichtheofficialmakesaspeech(asdefinedinRegulation18950(b)(2)),solongastheadmissionisprovidedbythepersonwhoorganizestheevent.

• Anyotherpaymentnotidentifiedabove,thatwouldotherwisemeetthedefinitionofgift,wherethepaymentismade by an individual who is not a lobbyist registered to lobbytheofficial’sstateagency,whereitisclearthatthegiftwasmadebecauseofanexistingpersonalorbusinessrelationshipunrelatedtotheofficial’spositionandthereis no evidence whatsoever at the time the gift is made to suggestthedonorhadapurposetoinfluenceyou.

To Complete Schedule D:• 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.


CALIFORNIA FORM

A M E N D M E N TSCHEDULE E

Income – GiftsTravel Payments, Advances,

and Reimbursements

Comments:

FPPC Form 700 (2015/2016) Sch. EFPPC Advice Email: [email protected]


• 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 $460 gift limit, but may result in a disqualifying conflict of interest.

• For gifts of travel that occurred on or after January 1, 2016, provide the travel destination.

DATE(S): / / - / / AMT:$ (If gift)





CITYANDSTATE

501(c)(3)orDESCRIBEBUSINESSACTIVITY,IFANY,OFSOURCE



CITYANDSTATE




CITYANDSTATE



Print Name






Filer’s Signature

►MUSTCHECKONE:

MadeaSpeech/Participated inaPanel

Other -ProvideDescription

Gift -or- Income

► IfGift,ProvideTravelDestination

►MUSTCHECKONE:



Gift -or- Income


►MUSTCHECKONE:



Gift -or- Income



FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.govInstructions - 7

TravelpaymentsreportableonScheduleEincludeadvancesandreimbursementsfortravelandrelatedexpenses,including lodging and meals.

Giftsoftravelmaybesubjecttothegiftlimit.Inaddition,certain travel payments are reportable gifts, but are not subjecttothegiftlimit.Toavoidpossiblemisinterpretationortheperceptionthatyouhavereceivedagiftinexcessofthegiftlimit,youmaywishtoprovideaspecificdescriptionofthepurposeofyourtravel.SeetheFPPCfactsheetentitled“LimitationsandRestrictionsonGifts,Honoraria,Travel,andLoans”atwww.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 governmentagencyandrelatedperdiemexpenseswhenthe 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 incomereportedonScheduleC.

• Atravelpaymentthatwasreceivedfromanon-profitentityexemptfromtaxationunderInternalRevenueCodeSection501(c)(3)forwhichyouprovidedequalorgreater consideration, such as reimbursement for travel on businessfora501(c)(3)organizationforwhichyouareaboard member.Note: Effective January, 2014, 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.• Checktheboxtoidentifythepaymentasagiftorincome,

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 $50ormorefromasinglesourceduringtheperiodcovered by the statement. Whenreportingtravelpaymentsthataregifts,youmust provide a description of the gift and the date(s) received.IfthetraveloccurredonorafterJanuary1,2016,youmustalsodisclosethe 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 $500ormorefromasinglesourceduringtheperiodcovered by the statement. You have the burden of proving the payments are income rather than gifts. Whenreportingtravelpaymentsasincome,youmustdescribetheservicesyouprovidedinexchangeforthepayment. You are not required to disclose the date(s) for travel payments that are income.

Example:City council member Rick Chandler is the chairman of a 501(c)(6)tradeassociationandtheassociationpaysforRick’straveltoattendits 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 ETravel Payments, Advances,

and Reimbursements

700 - fppc.ca.gov...See Reference Pamphlet, page 15, for more information on disclosing trusts. •...

Documents

Transcript of 700 - fppc.ca.gov...See Reference Pamphlet, page 15, for more information on disclosing trusts. •...