BOE-121

Source: https://www.boe.ca.gov/proptaxes/pdf/sample_boe121.pdf

BOE-121 REV. 02 (01-10)

Sta tement of Financial In terest

APPRAISER’S NAME EMPLOYED BY

INstruCtIoNs

You must complete this form or FPPC Form 700 at the time of temporary certification and each year thereafter in order to meet the certification requirement for the following year. This form, or FPPC Form 700, should be returned to, and retained by, your employer.

• Corporation: Enter the corporation name in which you have an interest and its address if its stock is not listed on an exchange. If you have no interest, write “none.”

• Nature of Interest: Check the type of interest you have (for example, common stock, preferred stock, or bonds or debentures).

• Quantity: Enter the number of certificates, shares, etc., you have.

• Ownership: Check whether held in joint or single ownership.

According to section 672 of Article 8 of Chapter 3 of Part 2 of Division 1 of the Revenue and Taxation Code, I hereby declare that my financial interest in any corporation or corporations is as follows:

Nature of INterest owNershIp
CorporatIoN QuaNtIty CommoN preferred BoNds or
JoINt sINgle stoCk stoCk deBeNtures

Remarks: SAMPLE

SIGNED DATE t