Form 700 Cover Page

Statement Of Economic Interests Cover Page - A Public Document

For Official Use Only: Date Received

California Form 700 (2012-2013) Fair Political Practices Commission
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Please type or print in ink:

Name of Filer: Last:

1. Office, Agency, or Court

Agency Name:

Division, Board, Department, District, if applicable:

Your position:

If filing for multiple positions, list below or on an attachment.


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


Multi-County:     Name of Counties

City: of:    Name of City:

Judge or Court Commissioner (State: wide Jurisdiction)

County of:  Name of County

Other:  Describe Other

3. Type of State: ment (Check at least one box)

Annual State: ment: The period covered is January 1, 2012, through December 31, 2012.

  • OR The period covered is:   Date (enter month, day, year) , through December 31, 2012.
Assuming Office State: ment:   Date (enter month, day, year)


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

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

(Check one)

  • The period covered is January 1, 2012, through the date of leaving office


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


4. Schedule Summary

Total number of pages including this cover page:

(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

5. Verification

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

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.)

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