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Form 700 Cover Page

STATEMENT OF ECONOMIC INTERESTS COVER PAGE A PUBLIC DOCUMENT

Please type or print in ink:

Name of Filer

Filer's Last Name:
Filer's First Name:
Filer's Middle Name:

Part 1. Office, Agency, or Court

Agency Name (Do not use acronyms):
Division, Board, Department, District, if applicable:
Your position:

If filing for multiple positions, list below or on an attachment.

Agency Name (Do not use acronyms):
Position:

Part 2. Jurisdiction of Office

Jurisdiction of Office (check at least one box) State
Multi-County, If multi-county checked, enter names of counties
City, If city checked, enter the city name
Judge, Retired Judge, Pro Term Judge, or Court Commissioner (Statewide Jurisdiction)
County, If county checked, enter the county name
Other, If other checked, describe other

Part 3. Type of Statement

Type of Statement (Check at least one box) Annual Statement: The period covered is January 1, 2021, through December 31, 2021.
Annual Statement: The period covered is your date through December 31, 2021.
If the period covered is your date, enter your date (month, day, year)
Assuming Office Statement
If Assuming Office Statement checked, enter assuming office date (month, day, year)
Candidate Statement
If Candidate Statement checked, enter date of election (month, day, year)
If Candidate Statement checked, enter office sought if different than Part 1 (Office, Agency, or Court)

Leaving Office Statement
If Leaving Office Statement checked, enter date left (month, day, year)

If Leaving Office checked, check one box The period covered is January 1, 2021, through the date of leaving office.
The period covered is your date, throught the date of leaving office.
If the period covered is your date, enter your date (month, day, year)

Part 4. Schedule Summary (must complete)

Schedule Summary (Check applicable schedules or None.) Schedule A-1 - Investments - schedule attached
Schedule A-2 - Investments - schedule attached
Schedule B - Real Property - schedule attached
Schedule C - Income, Loans and Business Positions - schedule attached
Schedule D - Income - Gifts - schedule Attached
Schedule E - Income - Gifts - Travel Payments - schedule attached
None - No reportable interests on any schedule

Total number of pages including this cover page:

Part 5. Verification

Mailing address (Business or Agency Address Recommended, Public Document)

Mailing Address Street
City
State
Zip Code
Daytime Telephone Number with area code
Email 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 (enter month, day, year)

Signature (Print this page and sign below with ink. Do not type signature)

(File the originally signed paper statement with your filing official.)

End of Title Page, Cover Page Form, HTML text-only version of Form 700, Years 2021 and 2022

Main Page
Quick Start Guide
Type of Statements
Cover Page Instructions
Cover Page
Schedule A-1 and A-2 Instructions
Schedule A-1 Form
Schedule A-2 Instructions
Schedule A-2 Form
Schedule B Instructions
Schedule B Form
Schedule C Instructions
Schedule C Form
Schedule D Instructions
Schedule D Form
Schedule E Instructions
Schedule E Form
Restrictions and Prohibitions
Questions and Answers

General Contact

Fair Political Practices Commission
1102 Q Street, Suite 3000
Sacramento, CA 95811

Email Advice: advice@fppc.ca.gov

General Contact Line: (916)322-5660
Advice Line: 1-866-ASK-FPPC (1-866-275-3772)