Free Contribution Disclosure for Agent - California

BOE-1400-C REV. 12 (`1-03)

STATE OF CALIFORNIA

CONTRIBUTION DISCLOSURE FOR AGENT (Attorney, Accountant, Consultant, Etc.)

BOARD OF EQUALIZATION
FOR OFFICE USE ONLY (DISCLOSURE ID)

Government Code Section 15626(e) requires that a party to, or a participant in, an adjudicatory proceeding pending before the Board shall disclose on the record of the proceeding any contribution or contributions made within the preceding 12 months by the party or participant, or his or her agent, to any Member of the Board. The Members of the State Board of Equalization are Betty T. Yee, Bill Leonard, Michelle Steel, Judy Chu, Ph.D. and State Controller John Chiang.
CASE ID FOR OFFICE USE ONLY (CLIENT ID)

NAME OF AGENT

ADDRESS (city, state, zip code)

1. List the party and/or participant(s) you represent in this case.
NAME OF PARTY

NAME OF PARTICIPANT(S)

YES

NO

2.

Have you made any contribution(s) to any State Board of Equalization Member in the past 12 months? If YES, please complete information about the contribution(s) at the bottom of this form. Are you an employee or member of any firm, company or similar entity? If YES, go to item 4; if NO skip to item 7.
ENTITY NAME FOR OFFICE USE ONLY (CLIENT ID)

3. 4.

ADDRESS (city, state, zip code)

5. List all "doing business as" or other corporate names used during the previous 12 months:

6. Has the entity made any contribution(s) to any State Board of Equalization Member in the past 12 months? If YES, please complete information about the contribution(s) at the bottom of this form. 7. This form must be signed by the authorized representative.
SIGNATURE(S) DATE

NAME(S) AND TITLE

PHONE NUMBER

CONTRIBUTIONS (Do not include contributions from Political Action Committees)
NAME CONTRIBUTED UNDER CONTRIBUTION DATE CONTRIBUTION AMOUNT NAME OF MEMBER

CLEAR

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