California
Form New Positions
Agency Report of:
1. Agency Name
Agency Contact
Email
(Also include, Division, Department, or Region (if applicable))
2. New Position Information
I have read and understand FPPC Regulations 18700.3 and 18734. I have verified that the disclosure assignment(s) set forth above, is in accordance with its provisions.
Comment: (Use this space or an attachment for any additional information.) FPPC Form 804 (2/16)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
804
Phone Number
Signature Name Title (month, day, year)
A Public Document
3. Verification
(month, day, year)
Date of Original Filing:
Amendment
Assuming/Start Date
(Optional)
Position Title/Classification
and Job Summary Assigned Category OR Disclosure Requirement Start /
m / d / yr
/
Start /
m / d / yr
/
Start /
m / d / yr
/
Start /
m / d / yr
/
Start /
m / d / yr
/
Start /
m / d / yr
/
Start /
m / d / yr
/
State and local government agencies may use this form
to identify new positions that will make or participate in making governmental decisions on behalf of the agency.
An individual in a newly created position must file a
Statement of Economic Interests (Form 700) within 30
days of assuming office.
This form identifies the Statement of Economic Interests, Form 700, disclosure requirements for individuals serving in new positions. This form is for the agency’s internal use and should be maintained by the agency in the same
manner as the agency’s conflict of interest code. For more information, refer to the FPPC website www.fppc.ca.gov
and Regulations 18700.3 and 18734.
Disclosure Requirements
y Disclosure requirements should conform to the range of duties.
y Alternatively, the agency must require an individual
to file under the broadest disclosure category in the
agency’s conflict of interest code or, if the agency does not have a conflict of interest code, full disclosure.
Full disclosure includes reporting all investments, business positions, and interests in real property held on the date of assuming office and income received during the 12
months immediately preceding assuming office.
When a new position is added, in addition to completing this form, the agency should begin the process to amend the conflict of interest code.
Examples:
An agency added a new data processing manager
position. The individual will be assigned the same
disclosure category that the agency’s other IT staff are assigned.
An agency implemented a new licensing program and a
new manager position was added. Because this was a
new program, the agency provided a written description
of the individual’s disclosure requirements which included sources subject to the licensing procedures.
An agency reorganized and changed the duties of several positions listed in the conflict of interest code. This form is not required as positions are not new. The agency should begin to amend its conflict of interest code if the range of authority and types of decisions changed.
An agency changed the titles but not the duties and
responsibilities of several positions. This form is not required. The agency must file an amendment to update
the conflict of interest code.
Instructions
Part 1
Identify the agency, contact information, and provide the amendment explanation in the comment section when
applicable.
Part 2
Identify the new position(s) and describe the position’s duties. Identify the disclosure by:
− Assigning an existing category(s) in the agency’s
code, or
− Writing a disclosure requirement.
Complete if the agency knows the employment date.
Part 3
The agency’s conflict of interest code should identify the position that is responsible for the verification.
Example
FPPC Form 804 (2/16)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
California
Form 804
A Public Document
Agency Report of:
New Positions
California
Form New Positions
Agency Report of:
1. Agency Name
Agency Contact
Email
(Also include, Division, Department, or Region (if applicable))
2. New Position Information
I have read and understand FPPC Regulations 18700.3 and 18734. I have verified that the disclosure assignment(s) set forth above, is in accordance with its provisions.
Signature Name
Comment: (Use this space or an attachment for any additional information.) FPPC Form 804 (9/11)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
804
Phone Number
Title (month, day, year)
A Public Document
3. Verification
(month, day, year)
Date of Original Filing:
Amendment
Assuming/Start Date
(Optional)
Position Title/Classification
and Job Summary Assigned Category OR Disclosure Requirement Start / m / d / yr
/
Start / m / d / yr
/
Start / m / d / yr
/
Start / m / d / yr
/
Start / m / d / yr
/
Start / m / d / yr
/
Start / m / d / yr
/
Data Processing Manager
(manages IT Dept)
to regulation by the
Department.
CA Joint Powers Authority
Smith, Adam Executive Director
555-555-5555 [email protected]
All investments, business
positions in business entities,
and sources
of income, including gifts, loans,
and travel payments, from
entities
that are of the type subject to
licensing by the Department or
are subject
3 ( , attach a
written explanation.)
Licensing Director
(duty statement attached)
Adam Smith Executive Director 3-10-XX
3 3 xx
3 8 xx
Adam Smith
Alternately