Hensley_Form_700_2017_2018//1� G�G�
Da�l/111i ved
• - • - 700 STATEMENT OF ECONOMIC INTERESTS �C I offal ly
A PUBLIC a • COVER PAGE
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Please type or print In Ink. G }� 3'
NAME OF FILER (LAST) /,<N
FIRST) (MIDDLE)
r l e ✓)S uV k— na ✓- i ^
1. Office, Agency, or
Agency Name (Do not use acronyms)
�'4 1) � 'F l
Division, Board, department, District,
Your Position
► If filing for multiple positions, list below or on an attachment. (Do not use acronyms)
Agency, Position,
2. Jurisdiction of Office (check at least one box)
❑ State ❑ Judge or Court Commissioner (Statewide Jurisdiction)
❑ Multi -County
1C� City of (i I 0
❑ County of
❑ Other
3. Type of Statement (check at least one box)
Annual: The period covered is January 1, 2017, through ❑ Leaving Office: Date Left I 1
December 31, 2017 (Check one)
-or-
The period covered is I I through
December 31, 2017.
❑ Assuming Office: Date assumed I i
❑ Candidate: Date of Election
O The period covered is January 1, 2017, through the date of
-or- leaving office.
O The period covered is I I through
the date of leaving office.
and office sought, if different than Part 1.
4. Schedule Summary (must complete) it. Total number of pages including this cover page:
Schedules attached
Schedule A-1 - Investments — schedule attached
Schedule A-2 - Investments — schedule attached
❑ Schedule B • Real Property — schedule attached
.or-
[:] None • No reportable interests on any schedule
5. Verification
Schedule C - Income, Loans, & Business Positions — schedule attached
C Schedule D - Income — Gifts — schedule attached
❑ Schedule E - Income — Gifts — Travel Payments — schedule attached
MAILING ADDRESS STREET CITY STATE ZIP CODE
(Business or Agency Address Recommended - Pub�k Document)
DAYTIME TELEPHONE NUMBER E-MAIL ADDRESS
( )
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
herein and in any attached schedules is true and complete. I acknowledge this is a public document.
I certify-undsr Ity of per)u under a laws of the State of California that the foregoing Is true and correct.
Date Signed Signature
(month, day, year) (Fie the originally signed statement m1h yow Ming olfidel.)
FPPC Form 700 (2017/2018)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll -Free Helpline: 866/275-3772 www.fppc.ca.gov
SCHEDULE A-1
9;
Investments FAIR POLITICAL PRACTICES COMMISSIO
Stocks, Bonds, and Other Interests Name 1�
(Ownership Interest is Less Than 100o)
Do' not attach brokerage or financial statements.
► NAME OF BUSINESS ENTITY
Kt � M r
GENERAL DESCRIPTION OF THIS BUSINESS
A re
I f �
FAIR MARKET VALUE
❑ $2,000 - $10,000 El $10,001 - $100,000
�$100,001 - $1,000,000 ❑ Over $1,000,000
NATURE OF INVESTMENT
❑ Stock ❑ Other
(Describe)
Partnership O Income Received of $0 - $499
Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
—J-1 17 1 / 17
ACQUIRED DISPOSED
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
❑ $2,000 - $10,000 ❑ $10,001 - $100,000
❑ $100,001 - $1,000,000 ❑ Over $1,000,000
NATURE OF INVESTMENT
❑ Stock ❑ Other
(Describe)
❑ Partnership O Income Received of $0 - $499
O Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/ 17 t / 17
ACQUIRED DISPOSED
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
❑ $2,000 - $10,000 ❑ $10,00, - $100,000
❑ $100,001 - $1,000,000 ❑ Over $1,000,000
NATURE OF INVESTMENT
❑ Stock ❑ Other
(Describe)
❑ Partnership O Income Received of $0 - $499
O Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
1 17
ACQUIRED DISPOSED
Comments:
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
❑ $2,000 - $10,000 ❑ $10,001 - $100,000
❑ $100,001 - $1,00a,000 ❑ Over $1,000,000
NATURE OF INVESTMENT
❑ Stock ❑ Other
(Describe)
❑ Partnership O Income Received of $0 - $499
O Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
I / 17 I / 17
ACQUIRED DISPOSED
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
❑ $2,000 - $10,000 ❑ $10,001 - $100,000
❑ $100,001 - $1,000,000 ❑ Over $1,000,000
NATURE OF INVESTMENT
❑ Stock ❑ Other
(Describe)
❑ Partnership O Income Received of $0 - $499
O Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
/ / 17 17
ACQUIRED DISPOSED
► NAME OF BUSINESS ENTITY
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE
❑ $2,000 - $10,000 ❑ $10,001 - $100,000
❑ $100,001 - $1,000,000 ❑ Over $1,000,000
NATURE OF INVESTMENT
❑ Stock ❑ Other
(Describe)
❑ Partnership O Income Received of $0 - $499
O Income Received of $500 or More (Report on Schedule C)
IF APPLICABLE, LIST DATE:
17 17
ACQUIRED DISPOSED
FPPC Form 700 (2017/2018) Sch. A-1
FPPC Advice Email: advice@fppc.ca.gov
FPPCToll-Free Flelpline:866/275-3772 www.fppc.ca.gov
SCHEDULE A-2
Investments, Income, and Assets
of Business Entities/Trusts
(Ownership Interest is 10% or Greater)
0- 1. BUSINESS ENTITY OR TRUST
Name
0 lu 01; ,l-t. r ✓ e,
Address (Business Address Acceptable)
Check one v1
❑ Trust, go to 2 ❑ Business Entity, complete the box, then_ go to 2
GENERAL DES RIPTION OF THIS BUSINESS
c c�J )I,-,- C h C&
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
❑ $0 - $1,999
❑ $2,000 - $10,000 / / 17 17
a10,001 - $100,000 ACQUIRED DISPOSED
$100,001 - $1,000,000
❑ Over $1,000,000
NATURE OF INV�S TENT
❑ Partnership �� ;ole Proprietorship ❑
Other
YOUR BUSINESS POSITION fo�evw,
GROSS• • • VIK VK4 KAIA
SHARE OF ••SS INCOME TO THE ENTITY1TRUST)
❑ $0 - $499 ❑ $10,001 - $100,000
❑ $500 - $1,000 IX
OVER $100,000
❑ $1,001 - $10,000
Im- 3. LIST THE NAME OF ••-TABLE SINGLE SOURCE OF
INCOMEOF $10,000 OR MORE
one or ❑ Names listed below
PROPERTYllp- 4. INVESTMENTS AND INTERESTS IN REAL • OR
LEASED BY THE BUSINESS ENTITY OR
Check one box
❑ INVESTMENT ❑ REAL PROPERTY
Name of Business Entity, if Investment, or
Assessor's Parcel Number or Street Address of Real Property
Description of Business Activity DI
City or Other Precise Location of Real Property
FAIR MARKET VALUE IF APPLICABLE, LIST DATE
❑ $2,000 - $10,000
❑ $10;001 - $1oo,000 /-J 77 -J__117
❑ $100-001 - $1,000,000 ACQUIRED DISPOSED
❑ Over $1,000,000
NATURE OF INTEREST
❑ Property Ownership/Deed of Trust ❑ Stock ❑ Partnership
❑ Leasehold ❑ Other
Yrs. remaining
❑ Check box K additional schedules reporting investments or real property
are attached
Comments:
Name
69_!S lc-
10 1. BUSINESS ENTITY OR TRUST
Name
Address (Business Address Acceptable)
Check one
❑ Trust, go to 2 ❑ Business Entity, complete the box, then go to 2
GENERAL DESCRIPTION OF THIS BUSINESS
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
❑ $0 - $1,999
❑ $2,000 - $10,000 �/ 17 �� 17
❑ $10,001 - $100,000 ACQUIRED DISPOSED
❑ $100,001 - $1,000,000
❑ Over $1,000,000
NATURE OF INVESTMENT
❑ Partnership ❑ Sole Proprietorship ❑
Other
YOUR BUSINESS POSITION
SHARE OF •SS INCOME TO THE ENTITYiTRUST)
❑ $0 - $499 ❑ $10,001 - $100,000
❑ $500 - $1,000 ❑ OVER $100,000
❑ $1,001 - $10,000
0- 3. LIST THE NAME OF -•-TABLE SINGLE SOURCE OF
❑ None or Names listed below
PROPERTYOR111� 4. INVESTMENTS AND INTERESTS IN REAL
LEASED BY THE BUSINESS ENTITY • TRUST
-
Check one boy
❑ INVESTMENT ❑ REAL PROPERTY
Name of Business Entity, if Investment, g[
Assessor's Parcel Number or Street Address of Real Property
Description of Business Activity DI
City or Other Precise Location of Real Property
FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
$2,.000 - $10,000
❑ $10.001 - $100,000 _I_! 1_7 // 17
❑ $100,001 - $1.000,000 ACQUIRED DISPOSED
❑ Over $1,000,000
NATURE OF INTEREST
❑ Property Ownership/Deed of Trust ❑ Stock ❑ Partnership
❑ Leasehold ❑ Other
Yrs remain,nq
❑ Check box if additional schedules reporting investments or real property
are attached
FPPC Form 700 (2017/2018) Sch. A-2
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll -Free Helpline: 866/275-3772 www.fppc.ca.gov
SCHEDULE C CALIFORNIAFORM
Income, Loans, & Business FAIR POLITICAL PRACTICES COMMI'
Positions Name
(Other than Gifts and Travel Payments) A4 a,(- � �L
NAME OF SOURCE OF INCOME
L :eio (r-
ADDRESS (Business Address Acceptable)
�g 5-5 :'. &n Ad j6je,, I 4,4
BUSINESS ACTIVITY, IF ANY, OF SOURCE
P'1 —�
c[ Q , r ti`T I f/Z ,
YOUR BUSINESS POSITION
GROSS INCOME RECEIVED ❑ No Income - Business Position Only
❑ $500 - $1,000 $1,001 - $10,000
❑ $10,001 - $100,000 'OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
❑ Salary Spouse's or registered domestic partrer's income
(For self-employed use Schedule P: 2 )
❑ Partnership (Less than 10% ownership. For 10% or greater use
Schedule A-2.)
❑ Sale of
(Real property! car, boat, etc.)
❑ Loan repayment
❑ Commission or ❑ Rental Income, list each source of $10,000 or more
(Describe)
NAME OF SOURCE OF INCOME
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF SOURCE
YOUR BUSINESS POSITION
GROSS INCOME RECEIVED ❑ No Income - Business Position Only
❑ $500 - $1,000 ❑ $1,001 - $10,00o
❑ $10,001 - $100,000 ❑ OVER $100,000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
❑ Salary ❑ Spouse's or registered domestic partner's income
(For self-employed use Schedule A-2.)
❑ Partnership (Less than 10% ownership. For 10% or greater use
Schedule A-2.)
❑ Sale of
❑ Loan repayment
(Real property, car, boat, etc.)
❑ Commission or ❑ Rental Income, list each source of $10,000 or more
(Describe)
Other ❑ Other (Describe) ❑ (Describe)
LOANS2. OR OUTSTANDING DURING THE REPORTING•D
* You are not required to report loans from commercial lending institutions, or any indebtedness created as part of a
retail installment or credit card transaction, made in the lender's regular course of business on terms available to
members of the public without regard to your official status. Personal loans and loans received not in a lender's
regular course of business must be disclosed as follows:
NAME OF LENDER`
ADDRESS (Business Address Acceptable)
BUSINESS ACTIVITY, IF ANY, OF LENDER
HIGHEST BALANCE DURING REPORTING PERIOD
❑ $500 - $1,000
❑ $1,001 - $10,0o0
❑ $10.001 - $100,000
❑ OVER $100.000
Comments:
INTEREST RATE TERM (MonthstYears)
ok ❑ None
SECURITY FOR LOAN
❑ None ❑ Personal residence
❑ Real Property
❑ Guarantor
❑ Other
Street address
City
(Desv,b^i
FPPC Form 700 (2017/2018) Sch. C
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll -Free Helpline: 866/275-3772 www.fppc.ca.gov