Fppc Form 700 - Statement Of Economic Interests - 2017/2018 Page 15

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700
SChEDuLE A-2
CALIFORNIA FORM
Investments, Income, and Assets
FAIr POLITICAL PrACTICES COMMISSION
Name
of Business Entities/Trusts
(Ownership Interest is 10% or Greater)
►
1. BuSINESS ENTITY Or TruST
►
1. BuSINESS ENTITY Or TruST
Name
Name
Address (Business Address Acceptable)
Address (Business Address Acceptable)
Check one
Check one
Trust, go to 2
Business Entity, complete the box, then go to 2
Trust, go to 2
Business Entity, complete the box, then go to 2
GENERAL DESCRIPTION OF THIS BuSINESS
GENERAL DESCRIPTION OF THIS BuSINESS
FAIR MARKET vALuE
IF APPLICABLE, LIST DATE:
FAIR MARKET vALuE
IF APPLICABLE, LIST DATE:
$0 - $1,999
$0 - $1,999
17
17
17
17
/
/
/
/
/
/
/
/
$2,000 - $10,000
$2,000 - $10,000
ACQuIRED
DISPOSED
ACQuIRED
DISPOSED
$10,001 - $100,000
$10,001 - $100,000
$100,001 - $1,000,000
$100,001 - $1,000,000
Over $1,000,000
Over $1,000,000
NATuRE OF INvESTMENT
NATuRE OF INvESTMENT
Partnership
Sole Proprietorship
Partnership
Sole Proprietorship
Other
Other
YOuR BuSINESS POSITION
YOuR BuSINESS POSITION
2. IDENTIFY ThE GrOSS INCOME rECEIVED (INCLuDE YOur PrO rATA
2. IDENTIFY ThE GrOSS INCOME rECEIVED (INCLuDE YOur PrO rATA
►
►
ShArE OF ThE GrOSS INCOME tO ThE ENTITY/TruST)
ShArE OF ThE GrOSS INCOME tO ThE ENTITY/TruST)
$0 - $499
$10,001 - $100,000
$0 - $499
$10,001 - $100,000
OvER $100,000
OvER $100,000
$500 - $1,000
$500 - $1,000
$1,001 - $10,000
$1,001 - $10,000
►
3. LIST ThE NAME OF EACh rEPOrTABLE SINGLE SOurCE OF
►
3. LIST ThE NAME OF EACh rEPOrTABLE SINGLE SOurCE OF
INCOME OF $10,000 Or MOrE
INCOME OF $10,000 Or MOrE
(Attach a separate sheet if necessary.)
(Attach a separate sheet if necessary.)
Names listed below
None
or
None
Names listed below
or
►
4. INVESTMENTS AND INTErESTS IN rEAL PrOPErTY hELD Or
►
4. INVESTMENTS AND INTErESTS IN rEAL PrOPErTY hELD Or
LEASED By ThE BuSINESS ENTITY Or TruST
LEASED By ThE BuSINESS ENTITY Or TruST
Check one box:
Check one box:
INvESTMENT
REAL PROPERTY
INvESTMENT
REAL PROPERTY
Name of Business Entity, if Investment, or
Name of Business Entity, if Investment, or
Assessor’s Parcel Number or Street Address of Real Property
Assessor’s Parcel Number or Street Address of Real Property
Description of Business Activity or
Description of Business Activity or
City or Other Precise Location of Real Property
City or Other Precise Location of Real Property
FAIR MARKET vALuE
IF APPLICABLE, LIST DATE:
FAIR MARKET vALuE
IF APPLICABLE, LIST DATE:
$2,000 - $10,000
$2,000 - $10,000
17
17
17
17
/
/
/
/
/
/
/
/
$10,001 - $100,000
$10,001 - $100,000
ACQuIRED
DISPOSED
ACQuIRED
DISPOSED
$100,001 - $1,000,000
$100,001 - $1,000,000
Over $1,000,000
Over $1,000,000
NATuRE OF INTEREST
NATuRE OF INTEREST
Property Ownership/Deed of Trust
Stock
Partnership
Property Ownership/Deed of Trust
Stock
Partnership
Leasehold
Other
Leasehold
Other
Yrs. remaining
Yrs. remaining
Check box if additional schedules reporting investments or real property
Check box if additional schedules reporting investments or real property
are attached
are attached
FPPC Form 700 (2017/2018) Sch. A-2
Comments:
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll-Free Helpline: 866/275-3772
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