HomeMy WebLinkAboutForm 804 - New Positions 2024
□
Agency Report of:
New Positions A Public Document
California
Form 804
1. Agency Name
(Also include, Division, Department, or Region (if applicable)) Amendment
Date of Original Filing:Agency Contact (month, day, year)
Phone Number Email
2. New Position Information
Position Title/Classification
and Job Summary Assigned Category OR Disclosure Requirement Assuming/Start Date
(Optional)
m / d / yr Start
m / d / yr Start
Start m / d / yr
m / d / yr Start
m / d / yr Start
m / d / yr Start
m / d / yr Start
3.Verification
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 Title (month, day, year)
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)
-□
___ _J
Agency Report of:
New Positions California
Form 804
A Public Document
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
Agency Report of:
New Positions A Public Document California
Form 804
1. Agency Name
Agency Contact
Email
(Also include, Division, Department, or Region (if applicable))
Phone Number
(month, day, year)
Date of Original Filing:
Amendment CA Joint Powers Authority
Smith, Adam Executive Director
555-555-5555 adam.smith@cjpa.ca.gov
2. New Position Information
Assuming/Start Date
(Optional)
Position Title/Classification
and Job Summary Assigned Category OR Disclosure Requirement
Data Processing Manager
(manages IT Dept)
3
Start 3
m / 3 / xx
/ d / yr
Licensing Director
(duty statement attached)
All investments, business
positions in business entities,
and sources Start 3 / 8 / xx
m / d / yr
of income, including gifts, loans,
and travel payments, from
entities Start m / // d / yr
that are of the type subject to
licensing by the Department or
are subject Start m / // d / yr
to regulation by the
Department. Start m / // d / yr
(Alternately , attach a
written explanation.) Start m / // d / yr
Start m / // d / yr
3. Verification
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.
Adam Smith Adam Smith
Signature Name
Comment: (Use this space or an attachment for any additional information.)
Executive Director
Title
3-10-XX
(month, day, year)
FPPC Form 804 (2/16)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Licensing Director
(duty statement attached)
3
3
3
Licensing Licensing Director Director
(duty (duty statement statement attached) attached)
Licensing Licensing Director Director
(duty (duty statement statement attached) attached)
Licensing Licensing Director Director
(duty (duty statement statement attached) attached)
Licensing Licensing Director Director
(duty (duty statement statement attached) attached)
3
3