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Agency Report of:
California
New Positions
804
Form
A Public Document
(Also include, Division, Department, or Region (if applicable))
1.Agency Name
Amendment
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Date of Original Filing:
Agency Contact
(month, day, year)
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Phone Number
Email
72:.7:2.6152
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2.New Position Information
Assuming/Start Date
Assigned Category OR Disclosure Requirement
and Job Summary
(Optional)
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6
1812 32
Start / /
m / d / yr
2-4-7-8
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18
2532
/ /
Start
m / d / yr
6-8
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Dppsejobups
2233
14
Start / /
m / d / yr
6-8
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122632
/ /
Start
m / d / yr
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181332
Start / /
m / d / yr
Start / /
m / d / yr
/ /
Start
m / d / yr
3.
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1:02:03133
Name Title (month, day, year)
Signature
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 804 (2/16)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
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Agency Report of:
California
804
New Positions
Form
A Public Document
State and local government agencies may use this form
to identify new positions that will make or participate in
making governmental decisions on behalf of the agency.
Statement of Economic Interests (Form 700) within 30
Instructions
Part 1
Identify the agency, contact information, and provide the
Form 700, disclosure requirements for individuals serving
amendment explanation in the comment section when
in new positions. This form is for the agency’s internal
applicable.
use and should be maintained by the agency in the same
Part 2
information, refer to the FPPC website
and Regulations 18700.3 and 18734.
Identify the new position(s) and describe the position’s
duties. Identify the disclosure by:
Disclosure Requirements
Assigning an existing category(s) in the agency’s
Disclosure requirements should conform to the range of
code, or
duties.
Writing a disclosure requirement.
Alternatively, the agency must require an individual
Complete if the agency knows the employment date.
Part 3
Full disclosure includes reporting all investments, business
positions, and interests in real property held on the date
Example
Agency Report of:
When a new position is added, in addition to completing
California
New Positions
804
Form
A Public Document
this form, the agency should begin the process to amend
(Also include, Division, Department, or Region (if applicable))
1. Agency Name
Amendment
CA Joint Powers Authority
Date of Original Filing:
Agency Contact
(month, day, year)
Smith, Adam Executive Director
Phone Number
Email
555-555-5555
adam.smith@cjpa.ca.gov
2. New Position Information
Assuming/Start Date
Assigned Category OR Disclosure Requirement
and Job Summary
(Optional)
Data Processing Manager
(manages IT Dept)
3
3
xx
3
Start / /
m / d / yr
All investments, business
Licensing Director Licensing Director
positions in business entities,
(duty statement attached) (duty statement attached)
3 8 xx
Start / /
assigned.
and sources
m / d / yr
of income, including gifts, loans,
Licensing Licensing Director Director
and travel payments, from
(duty (duty statement statement attached) attached)
3
Start / /
entities
m / d / yr
that are of the type subject to
Licensing Licensing Director Director
licensing by the Department or
3
(duty (duty statement statement attached) attached) Start / /
are subject
m / d / yr
to regulation by the
Licensing Licensing Director Director
3
Department.
(duty (duty statement statement attached) attached)
Start / /
m / d / yr
Licensing Licensing Director Director
(Alternately, attach a
3
(duty (duty statement statement attached) attached)
written explanation.)
Start / /
m / d / yr
/ /
Start
m / d / yr
3.
Adam Smith Executive Director 3-10-XX
Adam Smith
Signature Name Title (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 804 (2/16)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)