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Orange: BOE-121

Orange: BOE-121 for 2016

Statement of Financial Interest

INSTRUCTIONS

You must complete this form or FPPC Form 700 at the time of temporary certification and each year thereafter in order to meet the certification requirement for the following year. This form, or FPPC Form 700, should be returned to, and retained by, your employer.

•  Corporation: Enter the corporation name in which you have an interest and its address if its stock is not listed on an exchange.If you have no interest, write “none.”

•  Nature of Interest: Check the type of interest you have (for example, common stock, preferred stock, or bonds or debentures).

•  Quantity: Enter the number of certificates, shares, etc., you have.

•  Ownership: Check whether held in joint or single ownership.

According to section 672 of Article 8 of Chapter 3 of Part 2 of Division 1 of the Revenue and Taxation Code, I hereby declare that my financial interest in any corporation or corporations is as follows:



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Forms for use in 2016 will be available starting January 1st, 2016.

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