SCHEDULE E.

Income - Gifts Travel Payments, Advances, and Reimbursements
€ You must mark either the gift or income box.

ell Ark CALIFORNIA FORM FAIR r-tnrig:AL PRACTICES crialsmSatoN

€ Mark the "501(c)(3)" box for a travel payment received from a nonprofit 501(c)(3) organization or the "Speech" box if you made a speech or participated in a panel. These payments are not subject to the $440 gift limit, but may result in a disqualifying conflict of interest.
11.€ NAME OF SOURCE

(

Not an Acronym)

11.€ NAME OF ADOR. €
(

ADDRESS (Cfu , , iness A d ess A e CITY ANO STATE

~p 1 FT

2

c p

4c

URGE (Not an

_cronym)
4a SI ~4 4

taWe)

Business ddress Acceptable)

CITY ANO STATE p 501 (c1131 BUSINESS ACTIVITY, IF ANY, OF SOURCE € 501 (c1131

BUSINESS ACTIVITY, IF ANY. OF SOURCE
r

OATEISI:

c7 (~

i

gift)

AMTS

I

1 ,1 - ,r2. 7, (5 , i'l-DAT E(51: _t_i - ____t____, (if gi l)
TYPE OF PAYMENT. (must check one) 1361 ErMade a Speech/Parlicipaled In a Panel p Other - Provide Oescrlplion

-

~~~~~
€ Income

TYPE OF PAYMENT (rnu51 check one) Erg;II p Income 13 Made a Speech/Parllclpaled in a Panel p Olher ovlde Description 1- 4#S41/4--N:CrOtAi tl-----

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11.€ NAME OF SOURCE (Not en Acron )

AOORr i'Business Address Acceptable)

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e

\

1.- NAME OF SOURCE (Not en Acronym) ADDRESS (Business Address Acceptable) CITY AND STATE p 501 1c1131 BUSINESS ACTIVITY, IF ANY. OF SOURCE p 501 (c1(31

CITY ANO STATE BUSINESS ACTIVITY. IF ANY, OF SOURCE

CATE'S'.

./.1/_._
fir

1

AMT. S 1

%-

‚1 .71:9

CAT E (SI : _______/ /.

(tf gin)

- ____/.___/_._ AMT. S p Gift € Income

TYPE OF PAYMENT: (must check one)

p Gift p Income

TYPE OF PAYMENT: (mos' check one)

p Made a Speech/Participaled in a Panel K Olher - Provide Oescrlplion

p Made a SpeachiPartIcipaled in a Panel € Olher - Provide Oescriplion

(-0 EA,
Comments€

-

FPPC Form 7110 (2012120131 Sch. E FPPC Advice Email: advice0(ppc.ca,gov FPPC Toll-Free HelplIne- B661275-3772 www.(ppc.ca,gov

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