Susan Rodriguez - Annual 2012STATEMENT OF ECONOMIC INTERESTS
COVER PAGE
Please type or print in ink.
Date Received
NAME OF FILER (LAST) (FIRST) (MIDDLE)
Rodriguez Susan Elizabeth
1. Office, Agency, or Court
Agency Name
City of Gilroy
Division, Board, Department, District, if applicable Your Position
Physically Challenged Board of Appeals 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
❑ Multi- County _
0 City of
Gilroy
❑ Judge or Court Commissioner (Statewide Jurisdiction)
❑ County of
❑ Other
3. Type of Statement (Check at least one box)
0 Annual: The period covered is January 1, 2012, through ❑ Leaving Office: Date Left _— I
-or-
December 31, 2012. (Check one)
The period covered is ____I through O The period covered is January 1, 2012, through the date of
December 31, 2012. leaving office.
❑ Assuming Office: Date assumed I 1 O The period covered is ____I__ I through
the date of leaving office.
❑ Candidate: Election year
and 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 [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-
El 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
E-MAIL ADDRESS (OPTIONAL)
( 408 ) 848 -1775 - suezrod @msn.com
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 the foregoing is true and correct.
Date Signed 3f L2�Zv � Signature 4�
(month, day, year) (File the
with your filing official)
FPPC Form 700 (2012/2013)
FPPC Advice Email: advice @fppc.ca.gov
FPPC Toll -Free Helpline: 866 /275 -3772 www.fppc.ca.gov
SCHEDULE C CALIFORNIA FORM 1
Income, Loans, & Business •
Positions Name
(Other than Gifts and Travel Payments) CIM q
NAME OF SOURCE OF INCOME
Santa Clara Valley Medical Center
ADDRESS (Business Address Acceptable)
San Jose, CA
BUSINESS ACTIVITY, IF ANY, OF SOURCE
Hospital
YOUR BUSINESS POSITION
Respiratory Therapist 2
GROSS INCOME RECEIVED
❑ $500 - $1,000 F� $1,001 - $10,000
0 $10,001 - $100,000 ❑ OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
0 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 $to,000 or more
[Z Other,, Community Hospital, Watsonville,
C
NAME OF SOURCE OF INCOME
Good Samaritan Hospital
ADDRESS (Business Address Acceptable)
San Jose, CA
BUSINESS ACTIVITY, IF ANY, OF SOURCE
Hospital
YOUR BUSINESS POSITION
Respiratory Therapist
GROSS INCOME RECEIVED
❑ $500 - $1,000 ❑ $1,001 - $10,000
0 $10,001 - $100,000 ❑ OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
❑ Salary 0 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
❑ Other
* 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"
Wells Fargo Financial
ADDRESS (Business Address Acceptable)
Los Angeles, CA
BUSINESS ACTIVITY, IF ANY, OF LENDER
Home loan
HIGHEST BALANCE DURING REPORTING PERIOD
❑ $500 - $1,000
❑ $1,001 - $10,000
❑ $10,001 - $100,000
0 OVER $100,000
Comments:
INTEREST RATE TERM (Months/Years)
variable
W None
SECURITY FOR LOAN
❑ None 0 Personal residence
❑ Real Property
❑ Guarantor
❑ Other
Street address
City
(Describe)
FPPC Form 700 (2012/2013) Sch. C
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov