Form 700 Cover Page

Statement Of Economic Interests Cover Page - A Public Document

For Official Use Only: Date Initial Filing Received, Official Use Only

California Form 700 (2015-2016) Fair Political Practices Commission
Email Advice:
FPPC Toll-Free Helpline Call 1 (866) ASK-FPPC - (866) 275-3772

Please type or print in ink:

Name of Filer: Last: First: Middle:

1. Office, Agency, or Court

Agency Name (Do not use acronyms):

Division, Board, Department, District, if applicable:

Your position:

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

Agency: Position:

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


Multi-County: Name of Counties

City of: Name of City

Judge or Court Commissioner (Statewide Jurisdiction)

County of: Name of County

Other: Describe Other

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

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

  • OR The period covered is:   Date (enter month, day, year) , through December 31, 2015.
Assuming Office Statement:   Date (enter month, day, year)


Candidate Statement:   Election Year (enter year)  and office sought, if different than Part 1:

Leaving Office Statement:   Date Left (enter month, day, year)

(Check one)

  • The period covered is January 1, 2015, through the date of leaving office. OR
  • The period covered is   Date (enter month/day/year) , through the date of leaving office.

4. Schedule Summary

Check applicable schedules or "None."

Schedule A-1 - Investments - schedule attached

Schedule A-2 - Investments - schedule attached

Schedule B - Real Property - schedule attached

Schedule C - Income, Loans and Business Positions - schedule attached

Schedule D - Income - Gifts - shedule Attached

Schedule E - Income - Gifts - Travel Payments - schedule attached


None - No reportable interests on any schedule

Total number of pages including this cover page:

5. Verification

Mailing address (Business or Agency Address Recommended - Public Document)

Street: City: State: Zip code:

Daytime telephone number with area code:

E-mail Address (optional):

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):

Signature (Print this page and sign below with ink. Do not type signature)

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

[End of HTML text-only version of Form 700 (2015/2016) Cover Page]