HomeMy WebLinkAboutLeaving Office 2012STATEMENT OF ECONOMIC INTERESTS
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COVER PAGE
Please type or print in ink.
T F FILER (LAST) (FIRST) (MIDDLE)
l u&J Ate' I�Vm A --S-
1. Office, Agency, or Court
Agency Name
�Lep ClT�') ko L
Division, Board, Department, District, if applicable Your Position
C-,/ T CWt(/tu&
P. If filing for multiple positio s lis below or o tt chment.
Air
dy
Agency: 2071 (2t)W /?4'T5/0/W W(E' #12e on: ��rP
2. Jurisdiction of Office (Check at least one box)
❑ State
❑ Judge or Court Commissioner (Statewide Jurisdiction)
❑ Multi - County
County of -SA-1110 CL Xt
P5 City of (11
❑ Other
3. Type of Statement (Check at least one box)
�
❑ Annual: The period covered is January 1, 2011, through
/
E Leaving Office: Date Left �/s
December 31, 2011.
(Check one)
-or-
The period covered is
through O The period covered is January 1, 2011, through the date of
December 31, 2011.
leaving office. /
I he is �1_l through
11 Assuming Office: Date assumed I I
C period covered
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
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-
❑ None - No reportable interests on any schedule
5. Verification
MAILING ADDRESS STREET
(Business a ency Address Recommended - Public Document)
CITY STATE ZIP CODE
-PI/
9,"2(
i/u
D Y /IMEE(�TELEPH NE NUMBER //^
E -MAI L ADDRESS (OPTIONAL)
c�
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 for ing
Date Signed i642
(month, day, year)
Signature 7ha
(File the orrginall ed statement with 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
4eloa-�-:sy Sam
ADDRESS (Business Address Acceptable)
7 33 ; 6V 4b) Akfnk;►r klzy, , Cx
BUSINESS ACTIVITY, IF ANY, OF SOURCE
YOUR
�B1U^SIN�ESS POSITION
6 / v'"'
GROSS INCOME RECEIVED
❑ $500 - $1,000 ❑ $1,001 - $10,000
g-3•'r0,001 - $100,000 ❑ OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
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 310,000 or more
❑ Other
(Describe)
Name
r Dlua
NAME OF SOURCE OF INCOME
%xNA_1 r G',-- CAC SEW1 cL
ADDRESS (Business Address Acceptable)
BUSINESS ACCTIIVVIITYMIF ANY, OF SOURCE ty�
YOUR BUSINESS POSITION
1,009- POACNI" nA ,t7-D n
GROSS INCOME RECEIVED
❑ $500 - $1,000 ❑ $1,001 - $10,000
10,001 - $100,000 ❑ OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
❑ 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 or $10,000 or more
❑ Other
(Describe)
oo. 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
❑ Guarantor
❑ Other
Street address
City
(Describe)
FPPC Form 700 (2011/2012) Sch. C
FPPC Toll -Free Helpline: 866/275 -3772 www.fppc.ca.gov