Form Boe-1400-C - Contribution Disclosure For Agent (Attorney, Accountant, Consultant, Etc.)

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BOE-1400-C REV. 12 (`1-03)
STATE OF CALIFORNIA
CONTRIBUTION DISCLOSURE FOR AGENT
BOARD OF EQUALIZATION
(Attorney, Accountant, Consultant, Etc.)
FOR OFFICE USE ONLY (DISCLOSURE ID)
Government Code Section 15626(e) requires that a party to, or a participant in, an adjudicatory proceeding pending before the Board
shall disclose on the record of the proceeding any contribution or contributions made within the preceding 12 months by the party or
participant, or his or her agent, to any Member of the Board.
The Members of the State Board of Equalization are Betty T. Yee, Sen. George Runner, (Ret.), Michelle Steel, Jerome E. Horton, and
State Controller John Chiang.
CASE ID
FOR OFFICE USE ONLY (CLIENT ID)
NAME OF AGENT
ADDRESS (city, state, zip code)
1. List the party and/or participant(s) you represent in this case.
NAME OF PARTY
NAME OF PARTICIPANT(S)
NO
YES
2. Have you made any contribution(s) to any State Board of Equalization Member in the past 12 months? If YES,
please complete information about the contribution(s) at the bottom of this form.
3. Are you an employee or member of any firm, company or similar entity? If YES, go to item 4; if NO skip to item 7.
4.
ENTITY NAME
FOR OFFICE USE ONLY (CLIENT ID)
ADDRESS (city, state, zip code)
5. List all "doing business as" or other corporate names used during the previous 12 months:
6. Has the entity made any contribution(s) to any State Board of Equalization Member in the past 12 months? If YES,
please complete information about the contribution(s) at the bottom of this form.
7. This form must be signed by the authorized representative.
SIGNATURE(S)
DATE
NAME(S) AND TITLE
PHONE NUMBER
CONTRIBUTIONS (Do not include contributions from Political Action Committees)
NAME OF MEMBER
NAME CONTRIBUTED UNDER
CONTRIBUTION DATE
CONTRIBUTION AMOUNT
CLEAR
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