Fppc Form 700 - Statement Of Economic Interests Page 11

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700
caliFornia Form
schedule d
Fair Political Practices commission
income – gifts
a m e n d m e n t
► NAME OF SOuRCE (Not an Acronym)
► NAME OF SOuRCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
BuSINESS ACTIvITY, IF ANY, OF SOuRCE
BuSINESS ACTIvITY, IF ANY, OF SOuRCE
DATE (mm/dd/yy)
vALuE
DESCRIPTION OF GIFT(S)
DATE (mm/dd/yy)
vALuE
DESCRIPTION OF GIFT(S)
/
/
/
/
$
$
/
/
/
/
$
$
/
/
/
/
$
$
► NAME OF SOuRCE (Not an Acronym)
► NAME OF SOuRCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
BuSINESS ACTIvITY, IF ANY, OF SOuRCE
BuSINESS ACTIvITY, IF ANY, OF SOuRCE
DATE (mm/dd/yy)
vALuE
DESCRIPTION OF GIFT(S)
DATE (mm/dd/yy)
vALuE
DESCRIPTION OF GIFT(S)
/
/
/
/
$
$
/
/
/
/
$
$
/
/
/
/
$
$
Filer’s Verification
► NAME OF SOuRCE (Not an Acronym)
Print name
ADDRESS (Business Address Acceptable)
Office, Agency
or court
BuSINESS ACTIvITY, IF ANY, OF SOuRCE
statement type
2017/2018 Annual
Assuming
Leaving
Annual
Candidate
DATE (mm/dd/yy)
vALuE
DESCRIPTION OF GIFT(S)
(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
(month, day, year)
Filer’s Signature
comments:
FPPC Form 700 (2017/2018) Sch. D
FPPC Advice Email: advice@fppc.ca.gov
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FPPC Toll-Free Helpline: 866/275-3772

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