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Agency Name <br />Park and Recreation Commission <br />Division, Board, Department, District, if applicable Your Position <br />i* If feting for multiple positions, list below or on an attachment. <br />Agency: Position: <br />2. Jurisdiction of Office (Check at least one box) <br />❑ State ❑ Judge (Statewide Jurisdiction) <br />El Multi-County <br />r - ] Candidate: Election Year <br />❑ County of <br />Office sought, if different than Part 1: <br />4. Schedule Summary <br />Check applicable schedules or "None." P. Total number of pages including this cover page: <br />❑ Schedule A-1 - Investments - schedule attached F - j Schedule C - Income, Loans, & Business Positions - schedule attached <br />El Schedule A-2 • Investments - schedule attached ❑ Schedule D - Income - Gifts - schedule attached <br />El Schedule B • Real Properly - schedule attached ❑ Schedule E - Income - Gifts - Travel Payments - schedule attached <br />"or- <br />None - No reportable interests on any schedule <br />5. Verification <br />MAILING ADDRESS STRIEET CITY STATE ZIIP CODE <br />(Business or Agency Address Recommended - Public Documenll <br />NUMBER <br />E-MAIL ADDRESS <br />I have used ale reasonable diligence in preparing this statement. I have reviewed this statement and to the best of my knowledge the information contained <br />herein and in any attached schedules is true and complete. I acknowledge this is a public document. <br />I certify under penalty of perjury under the !laws of the State of California that the f <br />Date Signed Signature <br />(month, day, year) <br />