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CALIFORNIA • ' STATEMENT OF ECONOMIC INTEREST t <br /> FAIR POLITICAL PRACTICES COMMISSION <br /> A PUBLIC •• OCT �COVER PAGE 6 2012 <br /> Please type or print in ink. C;it <br /> e.^v of 1�q 616iE4—� <br /> NAME OF FILER (LAST) (FIRST) I t Y Clem�D C7e <br /> Larsen Nanci <br /> 1. Office, Agency, or Court <br /> Agency Name <br /> City of Riverside <br /> Division, Board, Department, District, if applicable Your Position <br /> Cultural Heritage Board Board Member <br /> ► If filing 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 or Court Commissioner(Statewide Jurisdiction) <br /> ❑Multi-County ❑County of <br /> Fx�City of Riverside ❑Other <br /> 3. Type of Statement (Check at Least one box) <br /> ❑ Annual: The period covered is January 1, 2011,through ❑x Leaving Office: Date Left 3 1 1 1 2011 <br /> December 31, 2011. (Check one) <br /> -or- <br /> The period covered is I I through ® The period covered is January 1,2011,through the date of <br /> December 31, 2011. leaving office. <br /> ❑ Assuming Office: Date assumed O The period covered is—J 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." ► 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- Travel 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 /> D <br /> ( <br /> I have use a reasona e 1 Igence In preparing is s a emen. ave reviewe Is s a emen n e y w tained <br /> herein and in any attached schedules is true and complete. I acknowledge thi <br /> I certify under penalty of perjury under the laws of the State of California <br /> Date Signed Sig <br /> (month,day,year) g official) <br /> Form 700(2011/2012) <br /> FPPC Toll-Free Helpline:866/275-3772 www.fppc.ca.gov <br />