Form 700-U - California Statement Of Economic Interests For Principal Investigators - Fair Political Practices Commissi Page 2
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3700-U
Date Received
Statement of economic intereStS
CALIFORNIA
Campus Use Only
FORm
for
FAIR POLItICAL PRACtICEs COmmIssION
PrinciPal inveStigatorS
Campus:
A Public Document
Please type or print in ink.
ID No:
NAmE
(LAST)
(FIRST)
(mIDDLE)
TELEPHoNE NUmbER
(
)
ACADEmIC UNIT oR DEPARTmENT
mAIL CoDE
E-mAIL ADDRESS
TITLE oF RESEARCH PRoJECT
1. Information Regarding Funding Entity
3. Filer Information -
Cont.
(Use a separate Form 700-U for each funding entity.)
D. Have you received loans from the entity in Part 1 for which
the balance exceeded $500 during the reporting period?
Name of Entity:
No
Yes
– highest balance:
$500 - $1,000
$1,001 - $10,000
Address of Entity:
$10,001 - $100,000
Exceeded $100,000
If you checked “yes,” was the loan:
Principal business of Entity:
Secured
Unsecured
Interest rate:
%
Was the loan entirely repaid within the last 12 months?
No
Yes
Amount of Funding: $
E. Have you received gifts from the entity listed in Part 1
Estimated
Actual
within the last 12 months valued at $50 or more?
No
Yes
– describe below.
2. type of statement
(Check at least one box)
Description:
Initial (for new funding)
Date of initial funding:
/
/
Interim (for renewed funding)
Value: $
Date Received:
/
/
Funding was renewed on:
/
/
F. Has the entity in Part 1 paid for your travel during the
reporting period?
No
Yes
– describe below.
3. Filer Information
A. Are you a director, officer, partner, trustee, consultant,
Type of Payment: (check one)
Gift
Income
employee, or do you hold a position of management in
Yes
the entity listed in Part 1?
No
Amt: $
date(s):
/
/
/
/
Title:
(If gift)
b. Do you, your spouse or registered domestic partner, or
Description and, if Gift, Travel Destination:
your dependent children have an investment of $2,000
or more in the entity listed in Part 1 above?
No
Yes
– value is:
$2,000 - $10,000
$10,001 - $100,000
4. Verification
$100,001 - $1,000,000
Exceeds $1,000,000
I have used all reasonable diligence in preparing this statement.
Date Disposed:
/
/
, if applicable
I have reviewed this statement and to the best of my knowledge
the information contained herein and in any attached schedules
C. Have you received income of $500 or more from the
is true and complete. I certify under penalty of perjury under the
entity listed in Part 1 during the reporting period?
laws of the State of California that the foregoing is true and correct.
No
Yes
– amount is:
$500 - $1,000
$1,001 - $10,000
Date signed
$10,001 - $100,000
Exceeds $100,000
(month, day, year)
Was this income received through your spouse or
signature
registered domestic partner?
No
Yes
(File the originally signed statement with your university.)
FPPC Form 700-U (2016/2017)
The Form 700-U is for university use only.
FPPC Advice Email: advice@fppc.ca.gov
This statement is a public record under Gov. Code Section 81008(a).
FPPC Toll-Free Helpline: 866/275-3772
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