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Form BOE-1400c Fillable Contribution Disclosure for Agent (Attorney, Accountant, Consultant, etc.)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)( 5 List all "doing business as" or other corporate names used during the previous 12 months:) (1 List the party and/or participant(s) you represent in this case NAME OF PARTY) (4 ENTITY NAME) (5 List all "doing business as" or other corporate names used during the previous 12 months) (7 This form must be signed by the authorized representative DATE) (7 This form must be signed by the authorized representative NAME(S) AND TITLE) (7 This form must be signed by the authorized representative PHONE NUMBER) (ADDRESS (city state zip code)) (Attorney Accountant Consultant Etc ) FOR OFFICE USE ONLY (DISCLOSURE ID) (CLEAR) CLEAR (CONTIBUTION DATE) (CONTIBUTION DATE) (CONTIBUTION DATE) (CONTRIBUTION AMOUNT) (CONTRIBUTION AMOUNT) (CONTRIBUTION AMOUNT) (CONTRIBUTIONS (Do not include contriburtions from Political Action Committees) Row 1 NAME CONTRIBUTED UNDER) (CONTRIBUTIONS (Do not include contriburtions from Political Action Committees) Row 2 NAME CONTRIBUTED UNDER) (CONTRIBUTIONS (Do not include contriburtions from Political Action Committees) Row 3 NAME CONTRIBUTED UNDER) (CONTRIBUTIONS (Do not include contriburtions from Political Action Committees) Row 4 NAME CONTRIBUTED UNDER) (CONTRIBUTIONS (Do not include contriburtions from Political Action Committees) Row 5 NAME CONTRIBUTED UNDER) (Government Code Section 15626(e) requires that a party to or a participant in an adjudicatory proceeding pending before the Boardshall disclose on the record of the proceeding any contribution or contributions made within the preceding 12 months by the party orparticipant or his or her agent to any Member of the Board The Members of the State Board of Equalization are Betty T Yee Michelle Steel Jerome E Horton State Controller John Chiang and Acting Member Barbara Alby CASE ID) (NAME OF AGENT) (NAME OF MEMBER) (NAME OF MEMBER) (NAME OF MEMBER) (NAME OF PARTICIPANT(S)) (PRINT) PRINT 1 List the party and/or participant(s) you represent in this case 2 Have you made any contribution(s) to any State Board of Equalization Member in the past 12 months? If YES 3 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 4 ENTITY NAME 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 7 This form must be signed by the authorized representative ADDRESS (city state zip code) BOE 1400 C REV 12 (`1 03) STATE OF CALIFORNIA CASE ID CONTRIBUTION DISCLOSURE FOR AGENT BOARD OF EQUALIZATION CONTRIBUTIONS (Do not include contributions from Political Action Committees) FOR OFFICE USE ONLY (CLIENT ID) Government Code Section 15626(e) requires that a party to or a participant in an adjudicatory proceeding pending before the Board NAME CONTRIBUTED UNDER CONTRIBUTION DATE CONTRIBUTION AMOUNT NAME OF MEMBER NAME OF AGENT NAME OF PARTICIPANT(S) NAME OF PARTY NAME(S) AND TITLE participant or his or her agent to any Member of the Board PHONE NUMBER please complete information about the contribution(s) at the bottom of this form shall disclose on the record of the proceeding any contribution or contributions made within the preceding 12 months by the party or SIGNATURE(S) State Controller John Chiang The Members of the State Board of Equalization are Betty T Yee Sen George Runner (Ret ) Michelle Steel Jerome E Horton and YES NO