AR 3 ATTACHMENT B District 4_Redacted — Pasadena City Council, April 19, 2023

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CITY OF PASADENA
APPLICATION FOR APPOINTMENT TOTtjEPASADENA RENTAL HOUSING BOAND FORM RHB-001
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The information contained on this form will be used by the City Council to fill vacancies on the Pasadena Rental Housing Board. Please answer all questions. You are invited to attach additional pages, a copy of your resume, or submit supplemental information which you feel may assist the City Council in its evaluation of your application. Applications will be purged from the City's files January 31 of each year. If you have not been appointed to the Rental hlousing Board and still desire to be considered for appointment, please resubmit an updated application, or advise City staff in writing that the initial form is still current and can be used for an additional year.

Applicant Name; '^•^pf?^' '^^;
Home Address:

Mailing Address:

Email Address:

Business Phone:

Home Phone:

REDACT!REDACTED

REDACTEDREDACTED
Date Available to Start: /^A€
Cell Phone:REDACTED
Board Seat Type: Indicate the type of Board seat in which you wish to fill (mark one or more):
^\ Tenant Member (7 seats, one per Council district, reserved for tenants) Representing City Council District
At-large Member (4 seats, open to any Pasadena resident without respect to tenancy or Council District)
Y Alternate Tenant Member (1 seat, reserved for tenants) X Alternate At-large Member (1 seat, open to any Pasadena resident without resfsect to tenancy or Council District)
Community Service - List boards, commissions, committees, and organizations on which you are currently serving or have served, offices held and in what city.

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Employment - Title and duties, current and past (acceptable to attach resume as an alternative).
'TM/p€fbry' j^b - ^€bo^"v/^ ^5S£STr^r/-4^^LXpr ^r^^sr
Education - Include professional or vocational licenses or certificates.

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1. Have you ever worked for the City of Pasadena? (If yes, please YES list dates/department)
NO

2. Are you related to any employee, appointed or elected official of YES j | the City of Pasadena? (If yes, please indicate name and relationship)
NO

3. Are you aware that financial disclosure is required annually? (e.g., sources of income, loans and gifts, investments, interests in real property)

4. Rules of law and ethics prohibit members from participating in and voting on matters in which they may have a direct or indirect financial interest. Are you aware of any potential conflicts of interest which may develop from your occupation, or economic holdings, in relation to your responsibilities as a member of the Rental Housing Board? (If yes, please indicate any potential conflicts)
YES
YES
NO
NO
NO

5. Do you,or your extended family1 members, have a material YES | | NO interest in rental property in the County of Los Angeles within the last three years?

6. Do you reside at a property owned or managed by a member of YES the City Council, or any member of the City Council's extended family, or in which any member of the City Council, or member of the City Council's extended family, has any ownership stake in said property?

7. Have there been, or are there now, any personal or business YES | | NO circumstances which might reflect adversely on the propriety of your serving as a member of the Pasadena Rental Housing Board?

8. Are you aware of the time commitment necessary to fulfill the YES |^l NO obligations of the Pasadena Rental Housing Board? '"
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' Extended Family: any spouse, whether by marriage or not, domestic partner, parent, child, sibling, grandparent, aunt or uncle, niece or nephew, grandchild, or cousin (Charter Section 1803(g».

9. Are you aware that you may serve no more than eight
consecutive years as a member of the Pasadena Rental
Housing Board?
YES^ NO Q

10. Describe your relevant life experience, professional training, and/or education in the following areas: Housing/Housing Justice/Landlord Tenant Relationships/Real Estate:
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11. How would you add value to the Pasadena Rental Housing Board? ^ X!\s€ >€^^ -EAJ ^ ^E^g^-j r/^ ^ ^t.^f •7t> /^^p tv^rf^ ^^I^HTU^ ttT %^r to/ur^x fi^fti^£, ^^^p.r ^ 77^- /a^//^ .r^- ^TC^S •7f> 77i^/, ^ soCLL 4^ ^P^fr/u T?/^ ^py^M< 4^'/S^/Lk /^h-?' ^TT^V -^<r f^lr/iirrp^ 0^ "n-t€ /^uew^i^rr..
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12. What do you view are the primary objectives and goals of the Pasadena Rental Housing Board?
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13. How would you help to achieve these objectives and goals? -TV X'Mfi^ri^t'iy ^ •^Mi^ J-7ztP^O.ir/v72M -77/r 'ho-rc^ £)F ^fen?P- ^\^f!^u^fj7
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I, '^o%"^< l^c/yRS'ho(printed name), declare under penalty of perjury under the law of the State of California that the information reported in this Form RHB-001 is true, accurate, and complete.

Signed this ^ day of -^g^^ 20 ^'S.

Signed: ^7/?A<T
1 Printed Name: 'fcfc^^r &^)S€^)
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CITY OF PASADENA
Residency Verification - MANDATORY
All applicants must provide proof of residency in a City Council district under section 1811(b) of The Pasadena Fair and Equitable Housing Charter Amendment (Measure H). Proof of residency may be established by either of the following:

1. If you are a registered voter, please complete and sign the following declaration and the City Clerk will verify your signature on file with the Los Angeles County Registrar of Voters.

I am a re
I reside
CA ^1/L
REDA

REDACTED
(zipc•Ik.
of the City of Pasadena
(street), Pasadena,
Signed: ^/lAJ
Printed Name: ^€^€/tr' ^^QB^bO

2. If you are not a registered voter, please provide clear, readable two forms of proof of residency acceptable to the Department of Motor Vehicles (DMV) for a REAL ID, listed below (Cal. Code Regs. tit. 13, § 17.00 and § 15.01 (d)).

Please provide clear, readable copies of two (2) documents from the following list and attach to this application:
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Home utility bill or cellular phone bill
Records from any state or national bank, state or federal savings association, trust company, industrial loan company, state or federal credit union, or any institution or entity that has issued a credit card
Insurance documents, including medical, dental, vision, life, home, rental or vehicle
Medical documents
A document issued by a U.S. government agency, meaning an entity, office, or authority governing over a country, state, county, city, municipality, district, agency, department, or any other political subdivision of a country or state Mortgage bill
Employment documents
Tax return (either Internal Revenue Service (IRS) or California Franchise Tax Board (FTB)
Rental or lease agreement with the signature of the owner/landlord and the tenant/resident
School documents issued by a public or private primary, secondary, or post- secondary institution, college, or university that includes the applicant's date of birth. If using a foreign school document, it must be sealed by the school and include a photograph of the applicant at the age the record was issued. sS
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Change of Address Confirmation by the U.S. Postal Service Property tax bill or statement
Letter attesting that the applicant resides in Pasadena from a homeless shelter, shelter for abused women, non-profit entity, faith-based organization, employer or government agency within the United States
Deed or title to residential real property
Voter registration confirmation letter or postcard issued by the California Secretary of State or the Los Angeles County Registrar of Voters Proof of payment of resident tuition at a public institution of higher education in California
An original copy of an approved Claim for Homeowners' Property Tax Exemption (BOE-266) form filed with the Los Angeles County Assessor Court documents that list the applicant as a resident of Pasadena California Certificate of Vehicle or Vessel Titles or registration (i.e., a title to, or a DMV registration for, a boat, truck or car)
A DMV No Fee Identification Card Eligibility Verification (DL 933) form, completed and signed
If your name does not appear on any residency documents, you may present a birth certificate, marriage license, or domestic partner registration certificate to trace your relationship to the person whose name does appear on the residency documentation.

If the residency document reflects a name that differs from the tracing document due to a name change (for example, marriage, divorce, or court order), name change documentation is required.
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CITY OF PASADENA
Supplement to Statement of Economic
Interest (FPPC Form 700)
(Form RHB-002)
All applicants must complete a Statement of Economic Interest (FPPC Form 700) and "Economic Interests Affidavit" attesting to the information reported in applicant's Form 700.

Instructions: The Pasadena Fair and Equitable Housing Charter Amendment (Measure H) prohibits Tenant Board and Alternate Tenant Board members from having "Material Interests in Rental Property" (defined below) at the time of their appointment and during their service. All applicants for all Board seats (both Tenant and At-Large) must report their own and their Extended Family's interests and dealings in rental properties in Los Angeles County in the three (3) years before submitting an application. The City is adopting the Fair Political Practices Commission's Form 700 for this purpose, but Measure H requires information about interests in rental property in Los Angeles County for three years, not the one year the FPPC Form otherwise uses. Under City Charter Section 1811(b), these documents are public records; they will not be confidential.

Measure H's Definitions;
Extended Family: any spouse, whether by marriage or not, domestic partner, parent, child, sibling, grandparent, aunt or uncle, niece or nephew, grandchild, or cousin (Section 1803(g)).

Material Interest in Rental Property: an individual has a Material Interest in Rental Property if they, or any member of their Extended Family, own, manage, or have a 5% or greater ownership stake in Rental Units in the county of Los Angeles, or if they or any member of their Extended Family owned, managed, or had a 5% or greater ownership stake in Rental Units in the county of Los Angeles in the past three (3) years (Section 1803(1)).

Rental Unit: any building, structure, or part thereof, or land appurtenant thereto, or any other rental property rented or offered for rent for residential purposes, whether or not such units possess a valid Certificate of Occupancy for use as rental housing, together with all housing services connected with use or occupancy of such property, such as common areas and recreational facilities held out for use by the Tenant (Section 1803(x)).

Tenant: a tenant, subtenant, lessee, sublessee or any other person entitled under the terms of a rental housing agreement to the use or occupancy of any Rental Unit (Section 1803(aa)).

CITY OF PASADENA
Economic Interests Affidavit - MANDATORY
I, l4^'^€/\jT C.$'C^)jf?feISO _ (printed name), declare under penalty of perjury under the law the State of California that the information provided and reported in this Form RHB-002 and the attached Form 700 is true, accurate, and complete.

Signed this J^ day of Y^B/U^
Signed: V]/rlAr,
_, 20 ^.

Printed Name-.l^'W^ Cscc^^^
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CITY OF PASADENA
Affidavit of Tenancy - MANDATORY for Tenant Board
and Tenant Alternate Seats
(Form RHB-003)
i, '^i^'tr ^^cc'sel^c' _(printed name), declare under penalty of perjury under the law of the State of California that the foregoing is true and correct:

1. lama tenant, subtenant, lessee, sublessee or any other person entitled under the terms of a rental agreement or lease (oral, written, or implied) for the use or occupancy of a rental unit.

2. I am either a) named in a rental housing agreement or lease, or b) have provided proof of a relationship to a person named in a rental agreement that entitles me the rights of a tenant.

3. I reside at the following
Pasadena, California ^llQ'7 (zip code)
(street),
OR
This form is not applicable to my application as I am not seeking a Tenant Board or Tenant Alternate Seat.

Signed this ^"^ day of ^%nftM/tft^
Signed: ^./IA~
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Printed Name: f^^SUT ^5^ff€h0
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CITY OF PASADENA

NOMINATION PETITION -WORKSHEET
P-ck/4- ^ScoUc
(Name of Candidate)
PaW P.-S^.o4- I/
(Office and District or Seat)
Total Signatures
Total OK 2-7
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Date: 3/2-3^^
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CITY OF PASADENA

APPLICATION FOR APPOINTMENT TO THE
PASADENA RENTAL HOUSING BOARD_
FORMRHB-001 2023 APR 14 PM K58
The information contained on this form will be used by the City Council to fill vacancies on the Pasadena Rental Housing Board. Please answer all questions. You are invited to attach additional pages, a copy of your resume, or submit supplemental information which you feel may assist the City Council in its evaluation of your application. Applications will be purged from the City's files January 31 of each year. If you have not been appointed to the Rental Housing Board and still desire to be considered for appointment, please resubmit an updated application, or advise City staff in writing that the initial form is still current and can be used for an additional year. ^ c?,^s
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Applicant Name:

Home Address:

Mailing Address:

Email Address:

Business Phone:

Home Phone:

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REDACTED

REDACTED
^^To—.

REDACTED
Date Available to Start:
^•^np'ifuvfy
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RED/ REDACTED
Board Seat Type: Indicate the type of Board seat in which you wish to fill (mark one or more):

Tenant Member (7 seats, one per Council district, reserved for tenants) Representing City Council District
irge Member (4 seats, open to any Pasadena resident without respect to tenancy or Council District)
i/ Alternate Tenant Member (1 seat, reserved for tenants) Member (1 seat, open to any Pasadena resident without
respect to tenancy or Council District)
Community Service - List boards, commissions, committees, and organizations on which you are currently serving or have served, offices held and in what city. ^!o^^ .
v.^
Employment - Title and duties, current and past (acceptable to attach resume as an alternative).
^\AA-i'co^— A~SS>'&+-A-^T^O-^^<-<rC^fr-^/Vy-\^^ — ^Q^S. (A,-e-.^1 c<JL ^i-n^^yc^^C^-iT^y ^aA-^'v^-'a
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Education - Include professional or vocational licenses or certificates. ^Sl^-c-^L. (^J^^jfc^-. >-t^\ ^-SL^'«-^ Q-N^-<^e-.
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1. Have you ever worked for the City of Pasadena? (If yes, please list dates/department)
YES NO

2. Are you related to any employee, appointed or elected official of the City of Pasadena? (If yes, please indicate name and relationship)

YESD NO

3. Are you aware that financial disclosure is required annually? (e.g., sources of income, loans and gifts, investments, interests in real property)

5. Do you,or your extended family1 members, have a material YES interest in rental property in the County of Los Angeles within the last three years?

7. Have there been, or are there now, any personal or business YES circumstances which might reflect adversely on the propriety of your serving as a member of the Pasadena Rental Housing Board?

8. Are you aware of the time commitment necessary to fulfill the YES obligations of the Pasadena Rental Housing Board?
D
NO
NO
@
D NO
NOD
Extended Family: any spouse, whether by marriage or not, domestic partner, parent, child, sibling, grandparent, aunt or uncle, niece or nephew, grandchild, or cousin (Charter Section 1803(g)). ,«fiS
c

9. Are you aware that you may serve no more than eight
consecutive years as a member of the Pasadena Rental
Housing Board?
YES@ No D

11. How would you add value to the Pasadena Rental Housing Board?•i •I

12. What do you view are the primary objectives and goals of the Pasadena Rental Housing Board?
r

13. How would you help to achieve these objectives and goals? l,\iJot—\-e.-ftTO ^aa*^-^"- ^T> -^a— (printed name), declare under penalty of perjury under the law of j the State of California that the information reported in this Form RhlB-001 is true, accurate, and complete.

Signed this 1'^ day oft^-^:l_, 20^^.

Signedj:^3(AjL^^ f^tJL^_(?l^—
Printed Name: \^3o-^ffc- fco-^fcy^- Vi-^s
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2 's
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1. If you are a registered voter, please complete and sign the following declaration and the City Clerk will verify your signature on file with the Los Angeles County Registrar of Voters.

I am a resident of District No.

REDACTED I reside at|
CA ^ 1\ <^^THITCBO^"
of the Citv of Pasadena
BREDACTED[street), Pasadena,
Signed
Printed Name:
: \^^jdG^- (\oJ<^^ P.^—^
^C^le-^-o— ^OL.^^VC- ^^^
^

Please provide clear, readable copies of two (2) documents from the following list and attach to this application:

Home utility bill or cellular phone bill
Records from any state or national bank, state or federal savings association, trust company, industrial loan company, state or federal credit union, or any institution or entity that has issued a credit card
Insurance documents, including medical, dental, vision, life, home, rental or vehicle
Medical documents
A document issued by a U.S. government agency, meaning an entity, office, or authority governing over a country, state, county, city, municipality, district, agency, department, or any other political subdivision of a country or state Mortgage bill
Employment documents
Tax return (either Internal Revenue Service (IRS) or California Franchise Tax Board (FTB)
Rental or lease agreement with the signature of the owner/landlord and the tenanVresident
School documents issued by a public or private primary, secondary, or post- secondary institution, college, or university that includes the applicant's date of birth. If using a foreign school document, it must be sealed by the school and include a photograph of the applicant at the age the record was issued. •
•
•
Change of Address Confirmation by the U.S. Postal Service Property tax bill or statement
Letter attesting that the applicant resides in Pasadena from a homeless shelter, shelter for abused women, non-profit entity, faith-based organization, employer or government agency within the United States
Deed or title to residential real property
Voter registration confirmation letter or postcard issued by the California Secretary of State or the Los Angeles County Registrar of Voters Proof of payment of resident tuition at a public institution of higher education in California
An original copy of an approved Claim for Homeowners' Property Tax Exemption (BOE-266) form filed with the Los Angeles County Assessor Court documents that list the applicant as a resident of Pasadena California Certificate of Vehicle or Vessel Titles or registration (i.e., a title to, or a DMV registration for, a boat, truck or car)
A DMV No Fee Identification Card Eligibility Verification (DL 933) form, completed and signed
If your name does not appear on any residency documents, you may present a birth certificate, marriage license, or domestic partner registration certificate to trace your relationship to the person whose name does appear on the residency documentation.

If the residency document reflects a name that differs from the tracing document due to a name change (for example, marriage, divorce, or court order), name change documentation is required.
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Measure H's^Definitipns;
Extended Family: any spouse, whether by marriage or not, domestic partner, parent, child, sibling, grandparent, aunt or uncle, niece or nephew, grandchild, or cousin (Section 1803(g)).

Tenant: a tenant, subtenant, lessee, sublessee or any other person entitled under the terms of a rental housing agreement to the use or occupancy of any Rental Unit (Section 1803(aa)).

CITY OF PASADENA
Economic Interests Affidavit - MANDATORY
,\j^cJtf-Vt&-)OAJ<—£:frs (printed name), declare under penalty of perjury under the lawI, of the State of California that the information provided and reported in this Form RHB-002 and the attached Form 700 is true, accurate, and complete.

Signed this l'^ day of 0^-f-^\ 20 ^-"^.
d: i^a^-*^ ^J^-^^^ —Signed:

Printed Name: ^<^\e.^-ct- ^c-»^^<^- ^T.'-A's
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RAS^o??A ^^' <?
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CITY OF PASADENA
Affidavit of Tenancy - MANDATORY for Tenant Board
and Tenant Alternate Seats
(Form RHB-003)
1, \JL\)L-\<^C- {^av^tf-vc-- K"^s (printed name), declare under penalty of perjury under the law of the State of California that the foregoing is true and correct:

1. I am a tenant, subtenant, lessee, sublessee or any other person entitled under the terms of a rental agreement or lease (oral, written, or implied) for the use or occupancy of a rental unit.

2. I am either a) named in a rental housing agreement or lease, or b) have provided proof of a relationship to a person named ii^y^g^g^^i^gyi^t entitles me the rights of a tenant.

3. I reside at the following address^_ (street),
Pasadena, California ^}}of (zi^o3e7
OR
This form is not applicable to my application as I am not seeking a Tenant Board or s
•s
Tenant Alternate Seat.

Signed this t'3- day of A^V—t _, 20 ^^:

Signed: \^>cA^K- (\^L^-G>; A-—^
Printed Name:^^e^r^ fo^Ax^<-^P'J^'y
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FTTAAAR

REDACTED REDACTED
CusTCTIWRERVICE AND
ABAPlTTS
|° PASADENA, CA
2023 APR 14 PM 1:58
E5TESL BILLER/COLLECTOR
L
Expert communicator, problem-solver and negotiator. Extensive experience in medical and business environments.

Created, trained and implemented integrated office protocols. Self-motivated; team player who also works well independently. Extremely well organized and skilled in research and writing. Conducted patient advocacy as an Ombudsman for diverse populations. Expertise in medical billing, clerical matters, bookkeeping, and payroll. Advocate and provider of care to special needs adults. Core Competencies:
13 Patient Advocacy
i3 Customer Service
0 Payment Processing
i3 Account Management
B Client Communications
Ei Insurance Liaison
a Billing Resolution
a Team Player
la Expert Negotiator
•CAREER HISTORY.

File Clerk, SCSEP, Department of Rehabilitation, State of CA, Pasadena, CA 2019-Present Labeled and updated paper files. Put files into their proper locations. Gathered and organized files and documents for coworkers' use, such as for reports. Maintained supply inventories. Answered inquiries regarding documentation organization. Photocopied and sent faxes. Sorted and sent mail.

Personal Assistant to Victoria Clausen, Altadena, CA 2011-2018 Answered phone calls and emails and took messages. Responsible for transportation to appointments. Assisted with daily time management. Ran errands as requested. Light housekeeping, planning and scheduling appointments, some meal preparation, socialization and entertainment.

Collections Representative | Patient Account Representative, Facey Medical Center, Mission Hills, CA 2007-2009 Served as a Patient Account Representative and Bill Collector. Managed outstanding claims with insurance carriers Responsible for answering incoming/outgoing calls. Processed patient payments and arranged payments. Contacted patients to resolve past due account balances. Collaborated with patients and health insurance representatives and other team members to resolve billing inconsistencies and errors.

Cashier and Stock Associate, CVS, Pasadena, CA 2006-2007 Managed cash register and communicated with customers and sales floor staff. Exceeded sales and promotional goals consistently. Provided excellent customer service to department store guests. Organized assigned departments and maintained cleanliness.

Collections Representative | Patient Account Representative 1997-2004 Cedars-Sinai Medical Center, Beverly Hills, CA
St. Luke Medical Center, Pasadena, CA
Served as a Patient Account Representative and Bill Collector. Managed outstanding claims with insurance carriers.

Oversaw accounts receivable, transfer of delinquent accounts to collection agencies, and patient inquiries. Managed outstanding claims with insurance carriers. Responsible for answering incoming/outgoing calls. Processed patient payments and arranged payments. Contacted patients to resolve past due account balances. Collaborated with patients, health insurance reprsentatives, and other team members to resolve billing inconsistencies and errors.

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-CREDENTIALS
Cedars-Sinai Medical Center Continuing Education, Beverly Hills, CA University of LaVerne, La Verne, CA
Milwaukee Area Technical College, Milwaukee, Wl
Microsoft Office including Word and Excel
-TECHNICAL SKILLS.

CITY OF PASADENA

NOMINATION PETITION - WORKSHEET
^arbcxYT^ '\^^'t^
(Name of Candidate)
T)^\
(Office and District dr Seat)
Total Signatures
Total OK
n
Date: -4-l4-^109,'5
Checked by:01

Pasadena City CouncilApril 19, 2023

Pasadena City Council
April 19, 2023