Fppc Form 700 - Statement Of Economic Interests Page 13
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14700
caliFornia Form
schedule e
Fair Political Practices commission
income – gifts
a m e n d m e n t
travel Payments, advances,
and reimbursements
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 gift limit, but may result in a disqualifying conflict of interest.
For gifts of travel, provide the travel destination.
•
► NAME OF SOuRCE (Not an Acronym)
► NAME OF SOuRCE (Not an Acronym)
ADDRESS (Business Address Acceptable)
ADDRESS (Business Address Acceptable)
CITY AND STATE
CITY AND STATE
501 (c)(3) or DESCRIBE BuSINESS ACTIvITY, IF ANY, OF SOuRCE
501 (c)(3) or DESCRIBE BuSINESS ACTIvITY, IF ANY, OF SOuRCE
/
/
/
/
/
/
/
/
DATE(S):
-
AMT: $
DATE(S):
-
AMT: $
(If gift)
(If gift)
► MuST CHECk ONE:
► MuST CHECk ONE:
Gift -or-
Gift -or-
Income
Income
Made a Speech/Participated in a Panel
Made a Speech/Participated in a Panel
Other - Provide Description
Other - Provide Description
► If Gift, Provide Travel Destination
► If Gift, Provide Travel Destination
Filer’s Verification
► NAME OF SOuRCE (Not an Acronym)
Print name
ADDRESS (Business Address Acceptable)
Office, Agency
or court
CITY AND STATE
statement type
2017/2018 Annual
Assuming
Leaving
Annual
Candidate
501 (c)(3) or DESCRIBE BuSINESS ACTIvITY, IF ANY, OF SOuRCE
(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.
/
/
/
/
DATE(S):
-
AMT: $
(If gift)
I certify under penalty of perjury under the laws of the State of
California that the foregoing is true and correct.
► MuST CHECk ONE:
Gift -or-
Income
Date Signed
Made a Speech/Participated in a Panel
(month, day, year)
Other - Provide Description
Filer’s Signature
► If Gift, Provide Travel Destination
comments:
FPPC Form 700 (2017/2018) Sch. E
FPPC Advice Email: advice@fppc.ca.gov
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FPPC Toll-Free Helpline: 866/275-3772
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