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Date Initial Filing Received
CALIFORNIA FORM 700 STATEMENT OF ECONOMIC INTERESTS
FAIR POLITICAL PRACTICES COMMISSION
A PUBLIC DOCUMENT COVER PAGE CIT, C_:PtKS OFF CE
Please type or print in ink. BY.
NAME OF FILER (LAST) (FIRST) (MIDDLE)
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1. Office, Agency, or Court
Agency Name (Do not use acronyms)
CIT'( 0-- R-o wt 442 CetA . p & Di tz_.
Division, Board. Department,t,LDistrict,
ifapplicable Your Position
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w If filing for multiple positions, list below or on an attachment. (Do not use acronyms)
Agency. Position:
2. Jurisdiction of Office (Check at least one box)
❑State ❑Judge or Court Commissioner(Statewide Jurisdiction)
❑Multi-County ❑County of _.
:City of Ez4ri1NeA D .. ❑Other ..
3. Type of Statement (Check at least one box)
❑ Annual: The period covered is January 1,2016, through ❑ Leaving Office: Date Left JJ
December 31, 2016. (Check one)
-Or-
The period covered is JJ __ ,through 0 The period covered is January 1, 2016,through the date of
December 31, 2016. leaving office.
Cit Assuming Office: Date assumed L l 22`p 17 O The period covered is through
the date of leaving office.
❑ Candidate: Election year and office sought, if different than Part 1:
4. Schedule Summary (must complete) ► Total number of pages including this cover page:
Schedules attached
❑ Schedule A•1 -Investments-schedule attached ❑Schedule C-Income, Loans. 8 Business Positions-schedule attached
❑ Schedule A-2-investments-schedule attached U Schedule D-Income- Gifts-schedule attached
❑ Schedule B • Real Property-schedule attached fl Schedule E-Income- Gifts- Travel Payments-schedule attached
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ne - No reportable interests on any schedule
5. Verification
MAILING ADDRESS STREET CITY STATE ZIP CODE
(Business or Agency Address Recommended-Dubin Document)
DAYTIME TELEPHONE NUMBER E-MAIL ADDRESS
( )
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 t(pc/ f 7 Signature
( IA den rear) (Poe be (near sand statement with your nig office/)
FPPC Form 700(2016/2017)
FPPC Advice Email:advice@fppc.ca.gov
FPPC Toll-Free Helpline:866/275-3772 www.fppc.ca.gov