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STATEMENT OF ECONOMIC
COVER PAGE
(LAST( (FIRST)
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1. Office, Agency, or Court
Agency Name
City of Rosemead
Division, Board, Department, District, if applicable Your Position
Parks and Recreation Recreation Supervision
► 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
❑x City of Rosemead
❑ Judge or Court Commissioner (Statewide Jurisdiction)
❑ County of
❑ Other
3. Type of Statement (check at least one box)
❑X Annual: The period covered is January 1, 2011, through
December 31, 2011.
-or-
The period covered is —� —J , through
December 31, 2011.
❑ Leaving Office: Date Left —_J__J
(Check one)
O The period covered is January 1, 2011, through the date of
leaving office.
❑ Assuming Office: Date assumed ---J---J O The period covered is 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 ❑ Schedule C - Income, Loans, & Business Positions - schedule attached
❑ Schedule A -2 - Investments - schedule allached ❑ Schedule D - Income - Gifts - schedule attached
0 Schedule B - Real Property - schedule attached ❑ Schedule E - Income - Gifts - Travel Payments - schedule attached
-or-
None - No reportable interests on any schedule
5. Verifi
MAILING ADDRESS STREET CITY STATE ZIP CODE
(Business w Agency Address Recommended - Pudic Document)
8838 E Valley Blvd Rosemead CA 91770
( 626 ) 569 -2100
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 i e 3ndorrect.
Date Signed February 9,2012 Signature
(month, day, yeah g
✓ FPPC Form 700 (2011 /2012)
FPPC Toll -Free Helpline: 8661275-3772 www.fppc.ca.gov
SCHEDULE B
Interests in Real Property
(Including Rental Income)
► ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS
9234 Guess Street
CITY
Rosemead
FAIR MARKET VALUE
❑ $2,000 - $10,000
❑ $10,001- $100,000
❑X $100,001 - $1,000,000
❑ Over $1,000,000
NATURE OF INTEREST
❑X Ownership /Deed or Trust
❑ Leasehold
Yrs_ remaining
IF APPLICABLE, LIST DATE:
J� 77 JJ 11
ACQUIRED DISPOSED
❑ Easement
0
Other
IF RENTAL PROPERTY, GROSS INCOME RECEIVED
❑ $0 - $499 ❑ $500 - $1,000 ❑ $1,001 - $10,000
❑ $10,001 - $100,000 ❑ OVER $100,000
SOURCES OF RENTAL INCOME: If you own a 10% or greater
interest, list the name of each tenant that is a single source of
income of $10,000 or more.
Name
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CITY
FAIR MARKET VALUE
❑ $2,000 - $10,000
❑ $10,001 - $100,000
❑ $100.001 - $1,000,000
❑ Over $1,000,000
NATURE OFINTEREST
❑ Ownership /Deed of Trust
IF APPLICABLE, LIST DATE:
ACQUIRED DISPOSED
❑ Easement
❑ Leasehold ❑
Ym. remaining Other
IF RENTAL PROPERTY, GROSS INCOME RECEIVED
❑ $0 - $499 ❑ $500 - $1,000 ❑ $1,001 - $10,000
❑ $10,001 - $100,000 ❑ OVER $100,000
SOURCES OF RENTAL INCOME: If you own a 10% or greater
interest, list the name of each tenant that is a single source of
income of $10,000 or more.
You are not required to report loans from commercial lending institutions 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
INTEREST RATE
❑ None
TERM (Months/Years)
HIGHEST BALANCE DURING REPORTING PERIOD
❑ $500 - $1,000 ❑ $1,001 - $10,000
❑ $10,001 - $100,000 ❑ OVER $100,000
❑ Guarantor, 'If applicable
Comments:
NAME OF LENDER`
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF LENDER
INTEREST RATE
% ❑ None
TERM (Months/Yeam)
HIGHEST BALANCE DURING REPORTING PERIOD
❑ $500 - $1,000 ❑ $1,001 - $10,000
❑ $10,001 - $100,000 ❑ OVER $100,000
❑ Guarantor, if applicable
FPPC Form 700 (201112012) Sch. B
FPPC Toll -Free Helpline: 866 1275 -3772 w ..fppc.ca.gov