Fppc Form 700 - Statement Of Economic Interests - 2017/2018 Page 5
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23Instructions
Cover Page
Enter your name, mailing address, and daytime telephone
• If your agency is not a state office, court, county office, city
number in the spaces provided. Because the Form 700 is
office, or multi-county office (e.g., school districts, special
a public document, you may list your business/office
districts and JPAs), check the “other” box and enter the
address instead of your home address.
county or city in which the agency has jurisdiction.
Part 1. Office, Agency, or Court
Example:
• Enter the name of the office sought or held, or the agency
This filer is a member of a water district board with jurisdiction
or court. Consultants must enter the public agency name
in portions of Yuba and Sutter Counties.
rather than their private firm’s name. (Examples: State
1. Office, Agency, or Court
Assembly; Board of Supervisors; Office of the Mayor;
Agency Name (Do not use acronyms)
Department of Finance; Hope County Superior Court)
Feather River Irrigation District
Division, board, Department, District, if applicable
Your Position
• Indicate the name of your division, board, or district, if
N/A
Board Member
applicable. (Examples: Division of Waste Management;
If filing for multiple positions, list below or on an attachment. (Do not use acronyms)
►
N/A
Board of Accountancy; District 45). Do not use acronyms.
Agency:
Position:
• Enter your position title. (Examples: Director; Chief
2. Jurisdiction of Office
(Check at least one box)
State
Judge or Court Commissioner (Statewide Jurisdiction)
Counsel; City Council Member; Staff Services Analyst)
Yuba & Sutter Counties
x
Multi-County
County of
• If you hold multiple positions (i.e., a city council member
City of
Other
who also is a member of a county board or commission),
Part 3. Type of Statement
you may be required to file statements with each agency.
Check at least one box. The period covered by a statement
To simplify your filing obligations, you may complete an
is determined by the type of statement you are filing. If you
expanded statement.
are completing a 2017 annual statement, do not change the
• To do this, enter the name of the other agency(ies) with
pre-printed dates to reflect 2018. Your annual statement is
which you are required to file and your position title(s) in
used for reporting the previous year’s economic interests.
the space provided. Do not use acronyms. Attach an
Economic interests for your annual filing covering January 1,
additional sheet if necessary. Complete one statement
2018, through December 31, 2018, will be disclosed on your
covering the disclosure requirements for all positions.
statement filed in 2019. See Reference Pamphlet, page 4.
Each copy must contain an original signature. Therefore,
Combining Statements: Certain types of statements may be
before signing the statement, make a copy for each
combined. For example, if you leave office after January 1,
agency. Sign each copy with an original signature and file
but before the deadline for filing your annual statement, you
with each agency.
may combine your annual and leaving office statements. File
If you assume or leave a position after a filing deadline,
by the earliest deadline. Consult your filing officer or the
you must complete a separate statement. For example, a
FPPC.
city council member who assumes a position with a county
Part 4. Schedule Summary
special district after the April 1 annual filing deadline must file
• Complete the Schedule Summary after you have reviewed
a separate assuming office statement. In subsequent years,
each schedule to determine if you have reportable
the city council member may expand his or her annual filing to
interests.
include both positions.
• Enter the total number of completed pages including the
Example:
cover page and either check the box for each schedule you
Scott Baker is a city council member for the City of Lincoln
use to disclose interests; or if you have nothing to disclose
and a board member for the Camp Far West Irrigation
on any schedule, check the “No reportable interests” box.
District – a multi-county agency that covers Placer and
Please do not attach any blank schedules.
Yuba counties. Scott will complete one Form 700 using full
disclosure (as required for the city position) and covering
Part 5. Verification
interests in both Placer and Yuba counties (as required for
Complete the verification by signing the statement and
the multi-county position) and list both positions on the Cover
entering the date signed. All statements must have an original
Page. Before signing the statement, Scott will make a copy
“wet” signature or be duly authorized by your filing officer to
and sign both statements. One statement will be filed with
file electronically under Government Code Section 87500.2.
City of Lincoln and the other will be filed with Camp Far West
Instructions, examples, FAQs, and a reference pamphlet are
Irrigation District. Both will contain an original signature.
available to help answer your questions. When you sign
Part 2. Jurisdiction of Office
your statement, you are stating, under penalty of perjury,
• Check the box indicating the jurisdiction of your agency
that it is true and correct. Only the filer has authority to sign
and, if applicable, identify the jurisdiction. Judges, judicial
the statement. An unsigned statement is not considered filed
candidates, and court commissioners have statewide
and you may be subject to late filing penalties.
jurisdiction. All other filers should review the Reference
Pamphlet, page 13, to determine their jurisdiction.
FPPC Form 700 (2017/2018)
FPPC Advice Email: advice@fppc.ca.gov
• If your agency is a multi-county office, list each county in
FPPC Toll-Free Helpline: 866/275-3772
which your agency has jurisdiction.
Instructions – 1
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