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700 Poulsen - Annual-Leaving (01-01-11 - 2-1-12)
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RECEIVED <br /> Date Received <br /> CALIFORNIA • - 700 STATEMENT OF ECONOMIC INTERESTS A`�rge°"x',12 <br /> FAIR POLITICAL PRACTICES COMMISSION <br /> A PUBLIC DOCUMENT COVER PAGE City of Riverside <br /> Please type or print in ink. City Clerk's Office <br /> NAME OF FILER (LAST) (FIRST) (MIDDLE) <br /> PQ ILA <br /> 1. Office, Agency, or Court <br /> Agency Name <br /> Division, Board, epartment, District, if applicable Your Position <br /> . ev .,l r-\,Qr. - 17� S- errztl Art A i pc+ t1'Pc,, <br /> ► If filing for multiple positions, list below or on an attachment. 7M r`' -6-P� � � <br /> Agency: Position: <br /> 2. Jurisdiction of Office (Check at least one box) <br /> ❑State ❑Judge or Court Commissioner(Statewide Jurisdiction) <br /> ❑Multi-County ❑County of <br /> WCity of-4\• V É>r�s ids ❑Other <br /> 3. Type of Statement (check at least one box) s� <br /> �l Annual: The period covered is January 1, 2011, through Leaving Office: Date Lefto-'u I�Ø� <br /> December 31, 2011. (Check one) <br /> -or- <br /> The period covered is I through The period covered is January 1, 2011, through the date of <br /> December 31, 2011. leaving office. <br /> ❑ Assuming Office: Date assumed 1 O The period covered is I I through <br /> the date of leaving office. <br /> ❑ Candidate: Election Year 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 Schedule C - Income, Loans, &Business Positions-schedule attached <br /> ❑ Schedule A-2 - Investments-schedule attached ❑ Schedule D - Income- Gifts-schedule attached <br /> Schedule B - Real Property-schedule attached ❑ Schedule E - Income- Gifts- 7-ravel Payments-schedule attached <br /> -or- <br /> ❑ None- No reportable interests on any schedule <br /> 5. Verification <br /> MAILING ADDRESS STREET CITY STATE ZIP CODE <br /> current) <br /> g 'A � <br /> E-MAIL ADDRESS(OPTIONAL) <br /> 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 <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 th <br /> Date Signed Z_ Signat <br /> (month,day,year) official)) <br /> FPPC Form 700(2011/2012) <br /> FPPC Toll-Free Helpline:866/275-3772 www.fppc.ca.gov <br />
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