Beverly Mabb - Morter - Annual RECEIVED ,
STATEMENT OF ECONOMIC INTERESTS DateQliiiiaPFil d
CALIFORNIA FORM700
Filing Official Use Only
FAIR POLITICAL PRACTICES COMMISSION COVER PAGE - JUN 0:18 _RECO
Please type or print in ink. A PUBLIC DOCUMENT CITY CLERK'S OFFICE
RY:
NAME OF FILER (LAST) (FIRST) ( DLE)
1. Office, Agency, or.Court_
Agency Name (Do not use acronyms) �!
V o QIV' k- 4 Poi i 41v Re cL 5 tiD vin vn i S 57 un t V
- Division, Board, Department, Dfstrict, if applicable Your Position
. 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, Retired Judge, Pro Tem Judge, or Court Commissioner
(Statewide Jurisdiction)
El Multi-County ❑County of
+E/City of 135. d Z.-dC ❑Other
3. Type of Statement (Check at least one box)
ErAnnual: The period covered is January 1,2019, through ❑ Leaving Office: Date Left_____/_/
December 31, 2019. (Check one circle.)
-or-
The period covered is_at I 0 II 9-.0 II,through 0 The period covered is January 1, 2019,through the date of
December 31, 2019. .or-leaving office.
❑ Assuming Office: Date assumed_____/ / 0 The period covered is J—__/ ,through ,
the date of leaving office.
. ❑ Candidate: Date of Election ' 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, &Business Positions–schedule attached
❑ Schedule A-2-Investments–schedule attached ❑Schedule D-Income–Gifts–schedule attached
B/Schedule B-Real Property–schedule attached ❑ Schedule E-Income–Gifts–Travel Payments–schedule attached
-or- ❑ None - No reportable interests on any schedule •
5. Verification �-Ogif1'u ot (xi- q11-70
MAILING ADDRESS STREET CITY S ATE ZIP CODE
(Business orAgencyAddress Recommended-Public Document)
DAYTIME TELEPHONE NUMBER EMAIL ADDRESS,,
)
(
I have used all reasonable diligence in preparing this statement. I have reviewed this statement and to theFiest of by knowledge the information contained
9 P P 9
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 it q( zuw Sign.so l !'i A I it i I - , ti "/.:
(month,day,year) (File the odd ly signed paper statement with your filing official.)
FPPC Form 700-Cover Page(2019/2020)
advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
Page-5
•
Instructions
Cover Page
Enter your name, mailing address, and daytime telephone • If your agency is a multi-county office, list each county in
number in the spaces provided. Because the Form 700 is which your agency has jurisdiction.
a public document,you may list your business/office • If your agency is not a state office, court, county office, city
address instead of your home address. office, or multi-countyoffice e.
( g., school districts, special
Part 1. Office,Agency, or Court districts and JPAs), check the"other" box and enter the
• Enter the name of the office sought or held, or the agency county or city in which the agency has jurisdiction.
or court. Consultants must enter the public agency name Example:
rather than their private firm's name. (Examples: State This filer is a member of a water district board with jurisdiction
Assembly; Board of Supervisors; Office of the Mayor; in portions of Yuba and Sutter Counties.
Department of Finance; Hope County Superior Court)
1.Office,Agency,or Court
• Indicate the name of your division, board, or district, ifAgency Name(Do nal use anonyms)
applicable. (Examples: Division of Waste Management; Feather River Irrigation District
Damon,Board,Department Dafitt R aPpGcable Your Poston
Board of Accountancy; District 45). Do not use acronyms. N/A Board Member
• Enter your position title. (Examples: Director; Chief .Bfling for mdtpleposNons,Gst below oronanattachment(Po not use acronyms)
Counsel; City Council Member; Staff Services Analyst) A
ge,N/A Podtnm
• If you hold multiple positions (i.e., a city council member 2.Jurisdiction ofOffice(Check atleast ono boat
State ['Judge or Court Commissioner(Statewide Judsdcton)
who also is a member of a county board or commission), prrwtzo.b, Yuba&Sutter Counties pcountyof
you may be required to file statements with each agency. ❑CRyof ❑Other
To simplify your filing obligations, you may complete an
Part 3. Type of Statement
expanded statement.
Check at least one box.The period covered by a statement
• To do this, enter the name of the other agency(ies) is determined by the type of statement you are filing. If you
with which you are required to file and your position are completing a 2019 annual statement, do not change the
title(s) in the space provided. Do not use acronyms. pre-printed dates to reflect 2020. Your annual statement is
Attach an additional sheet if necessary. Complete used for reporting the previous year's economic interests.
one statement covering the disclosure requirements Economic interests for your annual filing covering January 1,
for all positions. Each copy must contain an original 2020, through December 31, 2020,will be disclosed on your
signature. Therefore, before signing the statement, statement filed in 2021. See Reference Pamphlet, page 4.
make a copy for each agency. Sign each copy with an
original signature and file with each agency. Combining Statements: Certain types of statements may be
If you assume or leave a position after a filing deadline, combined. For example, if you leave office after January 1,
you must complete a separate statement. For example, a but before the deadline for filing your annual.statement,you
city council member who assumes a position with a county may combine your annual and leaving office statements. File
special district after the April annual filing deadline must file by the earliest deadline. Consult your filing officer or the
a separate assuming office statement. In subsequent years, FPPC.
the city council member may expand his or her annual filing to Part 4. Schedule Summary
include both positions. • Complete the Schedule Summary after you have reviewed
Example: each schedule to determine if you have reportable
Brian Bourne is a city council member for the City of Lincoln interests.
and a board member for the Camp Far West Irrigation • Enter the total number of completed pages including the
District—a multi-county agency that covers Placer and cover page and either check the box for each schedule you
Yuba counties. Brian will complete one Form 700 using full use to disclose interests; or if you have nothing to disclose
disclosure (as required for the city position) and covering on any schedule, check the"No reportable interests"box.
interests in both Placer and Yuba counties (as required for Please do not attach any blank schedules.
the multi-county position) and list both positions on the Cover
Page. Before signing the statement, Brian will make a copy Part 5. Verification
and sign both statements. One statement will be filed with Complete the verification by signing the statement and
City of Lincoln and the other will be filed with Camp Far West entering the date signed. All statements must have an original
Irrigation District. Both will contain an original signature. "wet"signature or be duly authorized by your filing officer to
Part 2. Jurisdiction of Office file electronically under Government Code Section 87500.2.
• Check the box indicating the jurisdiction of your agency When you sign your statement,you are stating, under
and, if applicable, identify the jurisdiction. Judges,judicial penalty of perjury,that it is true and correct. Only the filer
candidates, and court commissioners have statewide has authority to sign the statement. An unsigned statement
jurisdiction. All other filers should review the Reference is not considered filed and you may be subject to late filing
Pamphlet, page 13,to determine their jurisdiction. penalties.
FPPC Form 700-Cover Page(2019/2020)
advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
Page-6
•
SCHEDULE A-1
CALIFORNIA FORM 700
investments FAIR POLITICAL PRACTICES COMMISSION
Stocks, Bonds, and Other Interests Name
(Ownership Interest is Less Than 10%)
Investments must be itemized.
Do not attach brokerage or financial statements.
► NAMEiOF BUSINESSENTITY / II. NA,46I(kL E OF BUSINESS ENTIT
62,1 a Al r Sp2�/c I9 PrOc�u. -t' / LSI
GENERAL DESCRIPTION OF THIS BillISINESS GENERAL DESCRIPTION OF THIS BUSINESS
p111 /46v /0.64, f'S R c I r
FAIR MARKET VALUE FAIR MARKET VALUE
.$2,000-$10,000 0$10,001 -$100,000 [$2,000-$10,000 0$10,001 -$100,000
❑$100,001 -$1,000,000 ❑ Over$1,000,000 ❑$100,001 -$1,000,000 ❑Over$1,000,000
NATURE OF INVESTMENT NATURE OF INVESTMENT .
.Stock ❑Other j�Stock ['Other
, (Describe) T (Describe)
❑ Partnership 0 Income Received of$0-$499 ❑ Partnership 0 Income Received of$0-$499
0 Income Received of$500 or More(Report on Schedule C) 0 Income Received of$500 or More(Report on Schedule C)
IF APPLICABLE, LIST DATE: IF APPLICABLE, LIST DATE:
AC- QUIRED DISPOSED ACQUIRED,O/c- DISPOSED
► NAME OF BUSIN ENTITY C �) 10. NAME OF BUSINESS ENTITY
GENERAL SCRIPTION OF THIS BUSINESS GENERAL DESCRIPTION OF THIS BUSINESS
t pe Il'e / .0 co- $ e`er /
FAIR MARKET VALUE FAIR MARKET VALUE
0$2,000-$10,000 /$10,001 -$100,000 ❑$2,000-$10,000 0$10,001 -$100,000
0$100,001 -$1,000,000 ❑Over$1,000,000 ❑$100,001 -$1,000,000 ❑Over$1,000,000
NATURE OF INVESTMENT NATURE OF INVESTMENT
❑ Stock ❑Other ❑ Stock ❑Other
(Describe) (Describe)
[Partnership 0 Income Received of$0-$499 ❑ Partnership 0 Income Received of$0-$499
lit Income Received of$500 or More(Report on Schedule C) 0 Income Received of$500 or More(Report on Schedule C)
IF APPLICABLE, LIST DATE: IF APPLICABLE, LIST DATE:
_ / J ._____J__/. 19_ __/_.I._:_19_ _ J—_J9 ,
ACQUIRED DISPOSED ACQUIRED DISPOSED
► ME OF BU I ESS ENTITY ► NAME OF BUSINESS ENTITY
11 n CL,1? ' Capita-1 flls`e9e'et"
GENERAL DESC TION OF THIS BUSINESS GENERAL DESCRIPTION OF THIS BUSINESS
fled 15 M/e T-4 ve57/?¢4-f i ar,-
FAIR MARKET VALUE FAIR MARKET VALUE •
111$2,000-$10,000 10,001 -$100,000 0$2,000-$10,000 0$10,001 -$100,000
❑$100,001 -$1,000,000 ❑ Over$1,000,000 ❑$100,001 -$1,000,000 ❑Over$1,000,000
NATURE OF INVESTMENT NATURE OF INVESTMENT •
ock ['Other ❑ Stock ❑Other
(Describe)' (Describe)
❑ Partnership 0 Income Received of$0-$499 ❑ Partnership 0 Income Received of$0-$499
0 Income Received of$500 or More(Report on Schedule C) 0 Income Received of$500 or More(Report on Schedule C)
IF APPLICABLE, LIST DATE: IF APPLICABLE, LIST DATE:
—J_L_ _ J____I1� __1_1 '. . ___/_ 19
ACQUIRED DISPOSED ACQUIRED DISPOSED
Comments:
FPPC Form 700-Schedule A-1(2019/2020)
advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
Page-7
•
Instructions — Schedules A-1 and A-2
Investments
"Investment"means a financial interest in any business • Government defined-benefit pension plans(such as
entity(including a consulting business or other independent CaIPERS and CaISTRS plans)
contracting business)that is located in, doing business in, • Certain interests held in a blind trust(See Reference
planning to do business in, or that has done business during Pamphlet, page 16.)
the previous two years in your agency's jurisdiction in which
you,your spouse or registered domestic partner, or your Use Schedule A-1 to report ownership of less than 10%
dependent children had a direct, indirect, or beneficial interest (e.g., stock). Schedule C (Income) may also be required if
totaling$2,000 or more at any time during the reporting the investment is not a stock or corporate bond. (See second
period. (See Reference Pamphlet, page 13.) example below.)
Reportable investments include: Use Schedule A-2 to report ownership of 10%or greater
• Stocks, bonds,warrants, and options, including those held (e.g., a sole proprietorship).
in margin or brokerage accounts and managed investment To Complete Schedule A-1:
funds (See Reference Pamphlet, page 13.) Do not attach brokerage or financial statements.
• Sole proprietorships
• Your own business or your spouse's or registered •
Disclose the name of the business entity.
domestic partner's business (See Reference Pamphlet, • Provide a general description of the business activity of
page 8,for the definition of"business entity.") the entity(e.g., pharmaceuticals, computers, automobile
• Your spouse's or registered domestic partner's manufacturing, or communications).
investments even if they are legally separate property • Check the box indicating the highest fair market value of
• Partnerships(e.g., a law firm or family farm) your investment during the reporting period. If you are
filing a candidate or an assuming office statement, indicate
• Investments in reportable business entities held in a the fair market value on the filing date or the date you took
retirement account(See Reference Pamphlet, page 15.) office, respectively. (See page 20 for more information.)
• If you,your spouse or registered domestic partner, • Identify the nature of your investment(e.g., stocks,
and dependent children together had a 10%or greater warrants, options, or bonds).
ownership interest in a business entity or trust(including
a living trust),you must disclose investments held by the •
An acquired or disposed of date is only required if you
business entity or trust. (See Reference Pamphlet, page initially acquired or entirely disposed of the investment
16,for more information on disclosing trusts.) interest during the reporting period. The date of a stock
dividend reinvestment or partial disposal is not required.
• Business trusts Generally,these dates will not apply if you are filing a
You are not required to disclose: candidate or an assuming office statement.
• Government bonds, diversified mutual funds, certain Examples:
funds similar to diversified mutual funds(such as Frank Byrd holds a state agency position. His conflict of
exchange traded funds) and investments held in certain interest code requires full disclosure of investments. Frank
retirement accounts. (See Reference Pamphlet, page 13.) must disclose his stock holdings of$2,000 or more in any
(Regulation 18237) company that is located in or does business in California,
• Bank accounts, savings accounts, money market accounts as well as those stocks held by his spouse or registered
and certificates of deposits domestic partner and dependent children.
• Insurance policies Alice Lance is a city council member. She has a 4% interest,
• Annuities worth$5,000, in a limited partnership located in the city. Alice
• Commodities must disclose the partnership on Schedule A-1 and income of
• Shares in a credit union $500 or more received from the partnership on Schedule C.
• Government bonds(including municipal bonds)
• Retirement accounts invested in non-reportable interests
(e.g., insurance policies,mutual funds, or government
bonds) (See Reference Pamphlet, page 15.)
Reminders
• Do you know your agency's jurisdiction?
• Did you hold investments at any time during the period
covered by this statement?
• Code filers—your disclosure categories may only
require disclosure of specific investments.
FPPC Form 700(2019/2020)
advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
Page-8
SCHEDULE C CALIFORNIA FORM 700
. Income, Loans, & Business FAIR POLITICAL PRACTICES COMMISSION
Positions Name
(Other than Gifts and Travel Payments)
► 1.INCOME RECEIVED ► 1. INCOME RECEIVED
N OF SOUR E OF INCOME
-
� Ve NAME OF SOURCE OF INCOME
f ooy
DDRESSsiness Ad s Acce table) ADDRESS (Business Address Acceptable)
9//)---- 5 ee S� di,e,xa,,,-(
B ESS ACT.VITY, IF ANY,OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE
YOUR INESS P0'SITION YOUR BUSINESS POSITION
AA)(4. 41"
GROSS INCOME RECEIVED ❑No Income-Business Position Only GROSS INCOME RECEIVED ❑No Income-Business Position Only
❑$500-$1,000 ❑$1,001 -$10,000 ❑$500-$1,000 ❑$1,001 -$10,000
$10,001 -$100,000 ❑OVER$100,000 ❑$10,001-$100,000 ❑ OVER$100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED CONSIDERATION FOR WHICH INCOME WAS RECEIVED
❑Salary ❑Spouse's or registered domestic partner's income ❑Salary ❑Spouse's or registered domestic partner's income
(For self-employed use Schedule A-2.) (For self-employed use Schedule A-2.)
❑ Partnership(Less than 10%ownership. For 10%or greater use ❑ Partnership(Less than 10%ownership. For 10%or greater use
Schedule A-2.) Schedule A-2.) - •
❑Sale of ❑Sale of
(Real property,car,boat,etc.) (Real property,car,boat,etc.)
❑ Loan repayment • ❑ Loan repayment
•
❑ Commission or ❑ Rental Income,list each source of$10,000 or more ❑ Commission or ❑ Rental Income,list each source of$10,000 or more
(Describe) (Describe)
❑ Other ❑Other
(Describe) (Describe)
► 2.LOANS RECEIVED OR OUTSTANDING DURING THE REPORTING PERIOD
* You are not required to report loans from a commercial lending institution, 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* INTEREST RATE TERM(MonthslYears)
% ❑ None •
ADDRESS (Business Address Acceptable)
SECURITY FOR LOAN ,
BUSINESS ACTIVITY, IF ANY, OF LENDER ❑ None ❑ Personal residence
❑ Real Property
Street address
HIGHEST BALANCE DURING REPORTING PERIOD
❑$500-$1,000 City
❑$1,001 -$10,000
❑ Guarantor
❑$10,001 -$100,000
❑ OVER$100,000 ❑ Other
(Describe)
Comments:
FPPC Form 700-Schedule C(2019/2020)
• advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
Page-13
Instructions — Schedule C
Income, Loans, & Business Positions
(Income Other Than Gifts and Travel Payments)
Reporting Income: You are not required to report:
Report the source and amount of gross income of$500 or • Salary, reimbursement for expenses or per diem, or
more you received during the reporting period. Gross income social security, disability, or other similar benefit payments
is the total amount of income before deducting expenses, received by you or your spouse or registered domestic
losses, or taxes and includes loans other than loans from a partner from a federal, state, or local government agency.
commercial lending institution. (See Reference Pamphlet, • Stock dividends and income from the sale of stock unless
page 11.) You must also report the source of income to your the source can be identified.
spouse or registered domestic partner if your community • Income from a PERS retirement account.
property share was$500 or more during the reporting period.
The source and income must be reported only if the source (See Reference Pamphlet, page 12.)
is located in, doing business in, planning to do business in, To Complete Schedule C:
or has done business during the previous two years in your Part 1. Income Received/Business Position Disclosure
agency's jurisdiction. (See Reference Pamphlet, page 13.) • Disclose the name and address of each source of income
Reportable sources of income may be further limited by
your disclosure category located in your agency's conflict of or each business entity with which you held a business
interest code. position.
• Provide a general description of the business activity if the
Reporting Business Positions: source is a business entity.
You must report your job title with each reportable business • Check the box indicating the amount of gross income
entity even if you received no income during the reporting received.
period. Use the comments section to indicate that no income
was received. • Identify the consideration for which the income was
received.
Commonly reportable income and loans include: • For income from commission sales, check the box
• Salary/wages, per diem, and reimbursement for expenses indicating the gross income received and list the name of
including travel payments provided by your employer each source of commission income of$10,000 or more.
• Community property interest(50%) in your spouse's (See Reference Pamphlet, page 8.) Note: If you receive
or registered domestic partner's income-report the commission income on a regular basis or have an
employer's name and all other required information ownership interest of 10% or more,you must disclose
• Income from investment interests, such as partnerships, the business entity and the income on Schedule A-2.
reported on Schedule A-1 • Disclose the job title or business position, if any, that you
• Commission income not required to be reported on held with the business entity, even if you did not receive
Schedule A-2 (See Reference Pamphlet, page 8.) income during the reporting period.
• Gross income from any sale, including the sale of a house Part 2. Loans Received or Outstanding During the
or car(Report your pro rata share of the total sale price.) Reporting Period
• Rental income not required to be reported on Schedule B • Provide the name and address of the lender.
• Prizes or awards not disclosed as gifts • Provide a general description of the business activity if the
• Payments received on loans you made to others lender is a business entity.
• An honorarium received prior to becoming a public official • Check the box indicating the highest balance of the loan
(See Reference Pamphlet, page 10.) during the reporting period.
• Incentive compensation (See Reference Pamphlet, page • Disclose the interest rate and the term of the loan.
12.) - For variable interest rate loans, disclose the conditions
of the loan (e.g., Prime+2)or the average interest rate
paid during the reporting period.
Reminders - The term of the loan is the total number of months or
years given for repayment of the loan at the time the
• Code filers—your disclosure categories may not require loan was entered into.
disclosure of all sources of income. • Identify the security, if any, for the loan.
• If you or your spouse or registered domestic partner are
self-employed, report the business entity on Schedule A-2.
• Do not disclose on Schedule C income, loans, or business
positions already reported on Schedules A-2 or B.
FPPC Form 700 (2019/2020)
advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
Page-14
CALIFORNIA FORM 700
SCHEDULE B FAIR POLITICAL PRACTICES COMMISSION
Interests in Real Property Name
(Including Rental Income)
•
► ASSESSOR'S PARCEL1\I
`^� UM�R�R STREET
dry,-) . ADDRESS II. ASSESSOR'S PARCEL NUMBER OR STREET ADDRESS
e r/
,��� CITY
K oSCS i✓i0c
FAIR MARKET VALUE IF APPLICABLE, LIST DATE: FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
❑$2,000-$10,000 ❑$2,000-$10,000
❑$10,001 -$100,000 ��_.159_. _/_/_1_9_ ❑$10,001 -$100,000 _i-.__/19_ _J-_JC12_
64$100,001 -$1,000,000 ACQUIRED DISPOSED ❑$100,001 -$1,000,000 ACQUIRED DISPOSED
❑Over$1,000,000 0 Over$1,000,000
NATURE OF INTEREST NATURE OF INTEREST
Ownership/Deed of Trust ❑ Easement ❑ Ownership/Deed of Trust ❑ Easement
❑ Leasehold • ❑ ❑ Leasehold ❑
Yrs.remaining Other Yrs.remaining Other
IF RENTAL PROPERTY, GROSS INCOME RECEIVED IF RENTAL PROPERTY, GROSS INCOME RECEIVED
❑$0-$499 ❑$500-$1,000 ❑$1,001 -$10,000 0$0-$499 ❑$500-$1,000 ❑$1,001 -$10,000
❑$10,001 -$100,000 ❑OVER$100,000 . ❑$10,001 -$100,000 ❑OVER$100,000
SOURCES OF RENTAL INCOME: If you own a 10% or greater SOURCES OF RENTAL INCOME: If yoU own a 10% or greater
interest, list the name of each tenant that is a single source of interest, list the name of each tenant that is a single source of
income of$10,000 or more. income of$10,000 or more.
0 None ❑ None
•
* You are not required to report loans from a commercial lending institution 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* - NAME OF LENDER*
ADDRESS (Business Address Acceptable) ADDRESS (Business Address Acceptable) .
BUSINESS ACTIVITY, IF ANY, OF LENDER 'BUSINESS ACTIVITY, IF ANY,OF LENDER
INTEREST RATE TERM (Months/Years) INTEREST RATE TERM(Months/Years)
•
% ❑ None % ❑ None
•
HIGHEST BALANCE DURING REPORTING PERIOD HIGHEST BALANCE DURING REPORTING PERIOD .
❑$500-$1,000 ❑$1,001 -$10,000 ❑$500-$1,000 ❑$1,001 -$10,000
❑$10,001 -$100,000 ❑OVER$100,000 ❑$10,001 -$100,000 ❑ OVER$100,000
❑Guarantor, if applicable ❑ Guarantor, if applicable • '
Comments: •
. FPPC Form 700-Schedule B(2019/2020)
advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
Page-11
.
•
Instructions — Schedule B
Interests in Real Property
Report interests in real property located in your agency's disclose the number of years remaining on the lease.
jurisdiction in which you,your spouse or registered domestic • If you received rental income, check the box indicating the
partner, or your dependent children had a direct, indirect, or gross amount you received.
beneficial interest totaling$2,000 or more any time during • If you had a 10% or greater interest in real property and
the reporting period. Real property is also considered to be received rental income, list the name of the source(s) if
"within the jurisdiction" of a local government agency if the your pro rata share of the gross income from any single
property or any part of it is located within two miles outside tenant was$10,000 or more during the reporting period. If
the boundaries of the jurisdiction or within two miles of any you received a total of$10,000 or more from two or more
land owned or used by the local government agency. (See tenants acting in concert(in most cases,this will apply
Reference Pamphlet, page 13.) to married couples), disclose the name of each tenant.
Interests in real property include: Otherwise, mark"None."
• An ownership interest(including a beneficial ownership • Loans from a private lender that total$500 or more and
interest) are secured by real property may be reportable. Loans
• A deed of trust, easement, or option to acquire property from commercial lending institutions made in the
• A leasehold interest(See Reference Pamphlet, page 14.) lender's regular course of business on terms available
to members of the public without regard to your official
• A mining lease status are not reportable.
• An interest in real property held in a retirement account
(See Reference Pamphlet, page 15.) When reporting a loan:
• An interest in real property held by a business entity or Provide the name and address of the lender.
trust in which you,your spouse or registered domestic - Describe the lender's business activity.
partner, and your dependent children together had a 10% - Disclose the interest rate and term of the loan. For
or greater ownership interest(Report on Schedule A-2.) variable interest rate loans, disclose the conditions
• Your spouse's or registered domestic partner's interests in of the loan (e.g., Prime+2) or the average interest
real property that are legally held separately by him or her rate paid during the reporting period. The term of
a loan is the total number of months or years given
You are not required to report: for repayment of the loan at the time the loan was
• A residence, such as a home or vacation cabin, used established.
exclusively as a personal residence (However, a residence
in which you rent out a room or for which you claim a -
Check the box indicating the highest balance of the
business deduction may be reportable. If reportable, loan during the reporting period.
report the fair market value of the portion claimed as a tax - Identify a guarantor, if 4PARCEL
ER ORSTREET,�RESS60024th see
deduction.) applicable.
Sacramento
• Some interests in real property held through a blind trust If you have more than one ou. :S,o E IF AMICABLE,LIST DATE:
❑510 001-5,00.000 I-I _____,,a
(See Reference Pamphlet, page 16.) reportable loan on a single oam.�, �.� 5POSED
• Please note: A non-reportable property can still piece of real property, report NAnRE°FINTEREST
be grounds for a conflict of interest and may be the additional loan(s) on o „�' •Tryg of°'�^`
disqualifying. Schedule C. IF RENTAL PNOPER,,GRINCOME
OSS INM RECEIVED
❑50-se. IDsoo-5,00.0051.00,-5,0.000
To Complete Schedule B: Example: ' o OVER 5100 000
souR°E E.I,Y°u°wn a 10°b°r Orealer
Allison Gande is a city
• Report theprecise location (e.g.,
p an assessor's parcel planning commissioner. Henry wells
number or address) of the real property.
During the reporting period,
• Check the box indicating the fair market value of your NAME OF LENDER.
she received rental income of Sophia Petroillo
interest in the property(regardless of what you owe on the $12,000,from a single tenant 2121 gue Sky Parkwayo Sacramento
property). who rented property she
BUSINESS ACTIVITY,IF ANY.OF LENDER
• Enter the date acquired or disposed only if you initially owned in the city's jurisdiction. INTERRestaurantESTRATE Owner
TERM 15030505,51
acquired or entirely disposed of your interest in the If Allison received$6,000 8 ❑Non e ,s Yeas
property during the reporting period. each from two tenants,the HIGHEST BALANCE WRING REPORTING PERIOD
0 5500-51000 0 51,001-510,0°°
• Identify the nature of your interest. If it is a leasehold, tenants'names would not be 051°.001-5,°°°°° ❑ovER5,o0oa0
required because no single ❑s00000^ a.Vcade
Reminders tenant paid her$10,000 or
more. A married couple is °°”"`"ts'
• Income and loans already reported on Schedule B are considered a single tenant.
not also required to be reported on Schedule C.
• Real property already reported on Schedule A-2, Part 4
is not also required to be reported on Schedule B.
• Code filers—do your disclosure categories require
disclosure of real property?
FPPC Form 700(2019/2020)
advice@fppc.ca.gov•866-275-3772•www.fppc.ca.gov
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