Henry Servin - Assuming Office 2012CALIFORNIA FORm 700 1 STATEMENT OF ECONOMIC INTERESTS« I ;t, i
DOCUMENT FAIR POLITICAL PRACTICES COMMISSION
A PUBLIC COVER PAGE �QR 203 ''ti
Please type or print in ink.
NAME OF FILER (LAST) (FIRST) (MIDDLE)
Servin Henry
1. Office, Agency, or Court
Agency Name
City of Gilroy
Division, Board, Department, District, if applicable Your Position
Department of Public Works Senior Engineer
► If filing for multiple positions, list below or on an attachment.
Agency:
2. Jurisdiction of Office (Check at least one box)
Position:
❑ State ❑ Judge or Court Commissioner (Statewide Jurisdiction)
❑ Multi- County
m City of Gilroy
❑ County of
❑ Other
3. Type of Statement (Check at least one box)
Annual: The period covered is January 1, 2012, through ❑ Leaving Office: Date Left I I
-or-
December 31, 2012. (Check one)
°(VI
The period covered is I t through O The period covered is January 1, 2012, through the date of
December 31, 2012. leaving office.
dAssuming Office: Date assumed /Y I W/ O The period covered is _
the date of leaving office.
❑ Candidate: Election year
4. Schedule Summary
Check applicable schedules or "None."
❑ Schedule A -1 - Investments — schedule attached
❑ Schedule A -2 - Investments — schedule attached
❑ Schedule B - Real Property — schedule attached
and office sought, if different than Part 1:
o. Total number of pages including this cover page: 9
through
❑ Schedule C • Income, Loans, & Business Positions — schedule attached
❑ Schedule D - Income — Gifts — schedule attached
❑ Schedule E - Income — Gifts — Travel Payments — schedule attached
-or-
None - No reportable interests on any schedule
5. Verification
MAILING ADDRESS STREET CITY STATE ZIP CODE
(Business or Agency Address Recommended - Public Document)
7351 Rosanna Street Gilroy CA 95020
DAYTIME TELEPHONE NUMBER E -MAIL ADDRESS (OPTIONAL)
( 408 ) 846 -0451 1 henry.servin @ci.gilroy.ca.us
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 acknowledge this is a public document.
I certify under penalty of perjury under the laws of the State of California that
Date Signed 03/14/2013
(month, day, year)
Signature
correct.
V �eFma Form 700 (201212013)
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