Susan Rodriguez - Annual 2011Date Received
STATEMENT OF ECONOMIC INTERESTS Ylcia Use Only
FAIR POLITICAL LAAFUT+��—U-9'1111111bblfll i
A - DOCUMENT T COVER PAGE \0
Please type or print in ink.
NAME OF FILER (LAST) (FIRST) tMIDDLE)
Rodriguez Susan Elizabeth
1. Office, Agency, or Court
Agency Name
Physically Challenged Board of Appeals
Division, Board, Department, District, if applicable Your Position
of Gilroy Board Member
► If filing for multiple positions, list below or on an attachment.
Agency:
Position:
2. Jurisdiction of Office (Check at least one box)
❑ State
❑ Judge or Court Commissioner (Statewide Jurisdiction)
❑ Multi- County
❑ County of
❑X City of Gilroy
❑ Other
3. Type of Statement (Check at least one box)
Fx_1 Annual: The period covered is January 1, 2011, through
❑ Leaving Office: Date Left —J
December 31, 2011.
(Check one)
-or-
The period covered is —I
through O The period covered is January 1, 2011, through the date of
December 31, 2011.
leaving office.
❑ Assuming Office: Date assumed _ 1
O The period covered is I I through
the date of leaving office.
❑ Candidate: Election Year Office sought, if different than Part 1:
4. Schedule Summary
Check applicable schedules or "None."
► Total number of pages including this cover page:
❑ Schedule A -1 - Investments – schedule attached
❑X Schedule C - Income, Loans, & Business Positions – schedule attached
❑ Schedule A -2 - Investments – schedule attached
❑ Schedule D - Income – Gifts – schedule attached
❑ Schedule B - Real Property – schedule attached
❑ Schedule E - Income – Gifts – Travel Payments – schedule attached
'or-
E] None - No reportable interests on any schedule
5. Verification
MAILING ADDRESS STREET
CITY STATE ZIP CODE
(Business or Agency Address Recommended - Public Document)
9365 Lariat Drive
Gilroy CA 95020
DAYTIME TELEPHONE NUMBER
E -MAIL ADDRESS (OPTIONAL)
( 408 ) 848 -1775
1 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 the foregoing is true and correct.
Date Signed (2' Z 11 I Z
Signature
(m , day, year)
(File the originally sign st em your filing official.)
FPPC Form 700 (2011/2012)
FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov
SCHEDULE C
Income, Loans, & Business
Positions
(Other than Gifts and Travel Payments)
NAME OF SOURCE OF INCOME
Santa Clara Valley Medical Center
ADDRESS (Business Address Acceptable)
San Jose, CA
BUSINESS ACTIVITY, IF ANY, OF SOURCE
Registered Respiratory Therapist
YOUR BUSINESS POSITION
Respiratory Care Practioner
GROSS INCOME RECEIVED
❑ $500 - $1,000 ❑ $1,001 - $10,000
❑X $10,001 - $100,000 ❑ OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
❑X Salary ❑ Spouse's or registered domestic partner's income
❑ Loan repayment ❑ Partnership
❑ Sale of
(Real property, car, boat, etc.)
❑ Commission or ❑ Rental Income, list each source of $10,000 or more
NAME OF SOURCE OF INCOME
Watsonville Community Hospital
ADDRESS (Business Address Acceptable)
Watsonville, CA
BUSINESS ACTIVITY, IF ANY, OF SOURCE
Registered Respiratory Therapist
YOUR BUSINESS POSITION
Respiratory Care Practioner
GROSS INCOME RECEIVED
❑ $500 - $1,000 ❑ $1,001 - $10,000
❑X $10,001 - $100,000 ❑ OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
❑X Salary ❑ Spouse's or registered domestic partner's income
❑ Loan repayment ❑ Partnership
❑ Sale of
(Real property, car, boat, etc.)
❑ Commission or ❑ Rental Income, list each source of $10,000 or more
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❑ Other Other i ��, h P�rq J 4 (Describe) ( Descbe) i M l r�(� ` C �' L Y �rrt! 1f
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P- 2. LOANS RECEIVED OR OUTSTANDING DURING THE REPORTING PERIOD
* You are not required to report loans from commercial lending institutions, or any indebtedness created as part of a
retail installment or credit card transaction, made in the lender's regular course of business on terms available to
members of the public without regard to your official status. Personal loans and loans received not in a lender's
regular course of business must be disclosed as follows:
NAME OF LENDER'
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF LENDER
HIGHEST BALANCE DURING REPORTING PERIOD
❑ $500 - $1,000
❑ $1,001 - $10,000
❑ $10,001 - $100,000
❑ OVER $100,000
Comments:
INTEREST RATE TERM (Months/Years)
% ❑ None
SECURITY FOR LOAN
❑ None ❑ Personal residence
❑ Real Property
Street address
❑ Guarantor
❑ Other
City
(Describe)
FPPC Form 700 (2011/2012) Sch. C
FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov