California Form 700 - Statement Of Economic Interests Cover Page
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1
2Instructions
Cover Page
Enter your name, mailing address, and daytime telephone
• If your agency is not a state office, court, county office, city
number in the spaces provided. Because the Form 700 is
office, or multi-county office (e.g., school districts, special
a public document, you may list your business/office
districts and JPAs), check the “other” box and enter the
address instead of your home address.
county or city in which the agency has jurisdiction.
Part 1. Office, Agency, or Court
Example:
• Enter the name of the office sought or held, or the agency
This filer is a member of a water district board with jurisdiction
or court. Consultants must enter the public agency name
in portions of Yuba and Sutter Counties.
rather than their private firm’s name. (Examples: State
Part 3. Type of Statement
Assembly; Board of Supervisors; Office of the Mayor;
Department of Finance; Hope County Superior Court)
1. Office, Agency, or Court
Agency Name (Do not use acronyms)
• Indicate the name of your division, board, or district, if
Feather River Irrigation District
Division, Board, Department, District, if applicable
Your Position
applicable. (Examples: Division of Waste Management;
N/A
Board Member
Board of Accountancy; District 45). Do not use acronyms.
If filing for multiple positions, list below or on an attachment. (Do not use acronyms)
►
• Enter your position title. (Examples: Director; Chief
N/A
Agency:
Position:
Counsel; City Council Member; Staff Services Analyst)
2. Jurisdiction of Office
(Check at least one box)
State
Judge or Court Commissioner (Statewide Jurisdiction)
• If you hold multiple positions (i.e., a city council member
Yuba & Sutter Counties
x
Multi-County
County of
who also is a member of a county board or commission),
City of
Other
you may be required to file statements with each agency.
To simplify your filing obligations, you may complete an
Check at least one box. The period covered by a statement
expanded statement.
is determined by the type of statement you are filing. If you
are completing a 2015 annual statement, do not change the
• To do this, enter the name of the other agency(ies) with
pre-printed dates to reflect 2016. Your annual statement is
which you are required to file and your position title(s) in
used for reporting the previous year’s economic interests.
the space provided. Do not use acronyms. Attach an
Economic interests for your annual filing covering January 1,
additional sheet if necessary. Complete one statement
2016, through December 31, 2016, will be disclosed on your
covering the disclosure requirements for all positions.
statement filed in 2017. See Reference Pamphlet, page 4.
Each copy must contain an original signature. Therefore,
before signing the statement, make a copy for each
Combining Statements: Certain types of statements may be
agency. Sign each copy with an original signature and file
combined. For example, if you leave office after January 1,
with each agency.
but before the deadline for filing your annual statement, you
may combine your annual and leaving office statements. File
If you assume or leave a position after a filing deadline,
by the earliest deadline. Consult your filing officer or the
you must complete a separate statement. For example, a
FPPC.
city council member who assumes a position with a county
special district after the April 1 annual filing deadline must file
Part 4. Schedule Summary
a separate assuming office statement. In subsequent years,
• Complete the Schedule Summary after you have reviewed
the city council member may expand his or her annual filing to
each schedule to determine if you have reportable
include both positions.
interests.
Example:
• Enter the total number of completed pages including the
Scott Baker is a city council member for the City of Lincoln
cover page and either check the box for each schedule you
and a board member for the Camp Far West Irrigation
use to disclose interests; or if you have nothing to disclose
District – a multi-county agency that covers Placer and
on any schedule, check the “No reportable interests” box.
Yuba counties. Scott will complete one Form 700 using full
Please do not attach any blank schedules.
disclosure (as required for the city position) and covering
interests in both Placer and Yuba counties (as required for
Part 5. Verification
the multi-county position) and list both positions on the Cover
Complete the verification by signing the statement and
Page. Before signing the statement, Scott will make a copy
entering the date signed. All statements must have an original
and sign both statements. One statement will be filed with
“wet” signature or be duly authorized by your filing officer to
City of Lincoln and the other will be filed with Camp Far West
file electronically under Government Code Section 87500.2.
Irrigation District. Both will contain an original signature.
Instructions, examples, FAQs, and a reference pamphlet are
available to help answer your questions. When you sign
Part 2. Jurisdiction of Office
your statement, you are stating, under penalty of perjury,
• Check the box indicating the jurisdiction of your agency
that it is true and correct. Only the filer has authority to sign
and, if applicable, identify the jurisdiction. Judges, judicial
the statement. An unsigned statement is not considered filed
candidates, and court commissioners have statewide
and you may be subject to late filing penalties.
jurisdiction. All other filers should review the Reference
Pamphlet, page 13, to determine their jurisdiction.
FPPC Form 700 (2015/2016)
FPPC Advice Email: advice@fppc.ca.gov
• If your agency is a multi-county office, list each county in
FPPC Toll-Free Helpline: 866/275-3772
which your agency has jurisdiction.
Instructions – 1
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