"

CALIFORNIA FORM 700 STATEMENT OF ECONOMIC INTERESTS

FAIR POLITICAL PRACTICES COMMISSION

A PUBLIC DOCUMENT MAR 25 2011

LAKE COUNTY
Please type or print in ink. REGISTRAR VOTEftS
NAME OF FILER (LAST) ( 1.Sf) (MIDDLEI

Smith Jeffrey Merle

1. Office, Agency, or Court
Agency Name
County of Lake
Division, Board, Department, District, il applicable Your Position
Board of Supervisors District 2 Supervisor
~ II filing lor multiple positions, list below or on an attachment.

Agency: Position:

2. Jurisdiction of Office (Check at least one box)

o State o Judge (Statewide Jurisdiction)
t:)Multi.County _ _ _ _ _~_ _ _ _ _ _ _ _ __ Q9 County 01 _L_a_ke_ _ _ _ _ _ _ _ _ _ _ _ __
o City 01 _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ OOther _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3. Type of Statement (Check at least one box)

Q9 Annual: The period covered is Janu",)' 1, 2010, through December 31, o Leaving Office: Date Left ----.1----.-1_ _
2010. (Check one)
·or·
The period covered is --'----.-1_ _, through December 31, o The period covered is January 1, 2010, through the date 01
2010. leaving office.

o Assuming Office: Date --'----.-1_ _ o The period covered is ----.1--'_ _, through the date
01 leaving office.
o Candidate: Election Year _ _ _ _ __ Office sought, il different than Part 1: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

4. Schedule Summary
Check applicable schedules or 'Wone. II ~ Total number of pages including this cover page:

o Schedule A·1 • Inveslmenls - schedule attached o Schedule C • Income, Loans, & Business Positions - schedule attached
Q9 Schedule A·2 • Inveslmen/s - schedule attached o Schedule D • Income - Giffs - schedule attached
181 Schedule B • Real Property - schedule attached o Schedule E • Income - Giffs - Travel Payments - schedule attached
-or..
o None· No repOllable interests on any schedule

herein and in any attached schedules is true and complete. I acknowledge this is
I certify under penalty 01 perjury under the laws of the State of California tha

Date Signed _ _ _.:.M;.::a=;-re;c:;.h,'-C2=-4,-"e;2;.:0.:.1.:.1_ __

(month, day. year)

FPPC Form 700 (2010/2011)

FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
,,

SCHEDULE A-2 CALIFORNIA FORM

FAIR POLITICAL PRACTICES COMMISSION
700
Investments, Income, and Assets Name
of Business Entities/Trusts
(Ownership Interest is 10% or Greater) Jeff Smith

... 1 BUSINESS ENTITY OR TRUST ... 1 BUSINESS ENTITY OR TRUST

Jeff Smith's Clearlake Pure Water Jeff Smith Enterprises

Name Name
14420 Lakeshore Drl PO Box 3190 Clearlake, CA 95422 14420 Lakeshore Drl PO Box 3190 Clearlake, CA 95422
Address (Business Address Acceptable) Address (Business Address Acceptable)
Check one Check one
D Trust, go to 2 181 Business Entity, complete the box, then go to 2 o Trust, go to 2 1&1 Business Entity, complete the box, then go to 2

GENERAL DESCRIPTION OF BUSINESS ACTIVITY GENERAL DESCRIPTION OF BUSINESS ACTIVITY

Water Sales Guide, Rental & R&D
FAIR MARKET VALUE IF APPLICABLE, LIST DATE: FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
D $2,000 - $10,000 D $2,000 - $10,000
Qg $10,001 - $100,000 ~~~ ~~~ Qg $10,001 - $100,000 ~~ft ~~ft
D $100,001 - $1,000,000 ACQUIRED DISPOSED 0$100,001 - $1.000,000 ACQUIRED DISPOSED
DOver $1,000,000 DOver $1,000,000

NATURE OF INVESTMENT NATURE OF INVESTMENT

I&] Sole Proprietorship D Partnership D 1&1 Sale Proprietorship D Partnership D
Other Other
YOUR BUSINESS POSITION YOUR BUSINESS POSITION

III- 2 IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA III- 2 IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA
SHARE OF THE GROSS INCOME TO THE ENTITY/TRUST) SHARE OF THE GROSS INCOME TO THE ENTITYITRUST)

D $0-$499 D $10,001 - $100,000 D $0-$499 D $10,001 - $100,000

D $500 - $1,000 DOVER $100,000 D $500 - $1,000 DOVER $100,000
Qg $1,001 - $10,000 D $1,001 - $10,000
III- 3 LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF III- 3 LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF
INCOME OF $10,000 OR MORE (Att~d' ~ 5~p~,atG sheet ,I fle~e~~Jryl INCOME OF $10,000 OR MORE IAtt~ch 3 5cp~'~te .~cet tf flcce .. ~ry I

III- 4 INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD BY THE III- 4 INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD BY THE
BUSINESS ENTITY OR TRUST BUSINESS ENTITY OR TRUST
Check one box: Check one box:
D INVESTMENT D REAL PROPERTY D INVESTMENT· D REAL PROPERTY

Name of Business Entity Q[ Name of Business Entity Q[

Street Address or Assessor's Parcel Number of Real Property Street Address or Assessor's Parcel Number of Real Property

Description of Business Activity Q[ Description of Business Activity Q[

City or Other Precise Location of Real Property City or Other Precise Location of Real Property

FAIR MARKET VALUE IF APPLICABLE, LIST DATE: FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
D $2,000 - $10,000 D $2,000 - $10,000
D $10,001 - $100,000 ~~~~~~ D $10,001 - $100,000 ~~~~~~
D $100,001 - $1,000,000 ACQUIRED DISPOSED o $100,001 - $1,000,000 ACQUIRED DISPOSED
DOver $1,000,000 DOver $1,000,000

NATURE OF INTEREST NATURE OF INTEREST

o Property Ownership/Deed of Trust D Stock D Partnership D Property Ownership/Deed of Trust D Stock o Partnership
D Leasehold Yrs. remaining D Othe' _ _ _ _ _ _ _ __ D Leasehold D Othe' _ _ _ _ _ _ _ __
Yrs. remaining
D Check: box if additional schedules reporting investments or real property D Check box if additional schedules reporting investments or real property
are attached are attached
Cornmenm: _________________________
FPPC Form 700 (201012011) Sch. A-2
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
"

SCHEDULE A-2 CALIFORNIA FORM 700

FAIR POLITICAL PRACTICES COMMISSION
Investments, Income, and Assets
Name
of Business Entities/Trusts
(Ownership Interest is 10% or Greater) Jeff Smith

II- 1 BUSINESS ENTITY OR TRUST III> 1 BUSINESS ENTITY OR TRUST

Clearlake Electrolysis Center

Name Name
14420 Lakeshore Dr/PO Box 3190 Clearlake, CA 95422
Address (Business Address Acceptable) Address (Business Address Acceptable)
Check one Check one
o Trust, go to 2 ~ Business Entity, complete the box, then go to 2 D Trust, go to 2 D Business Entity, complete the box, then go to 2

GENERAL DESCRIPTION OF BUSINESS ACTIVITY GENERAL DESCRIPTION OF BUSINESS ACTIVITY

Electrolysis
FAIR MARKET VALUE IF APPLICABLE, LIST DATE: FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
D $2,000 - $10,000 D $2,000 - $10,000
D $10,001 - $100,000 ----.1----.1.JJL ~~.JJL D $10,001 - $100,000 ----.1----.1.JJL ----.1----.1..1Q..
D $100,001 - $1,000,000 ACQUIRED DISPOSED D $100,001 - $1,000,000 ACQUIRED DISPOSED
DOver $1,000,000 DOver $1,000,000

NATURE OF INVESTMENT NATURE OF INVESTMENT

1&1 Sole Proprietorship D Partnership D D Sole Proprietorship D Partnership D
Oth" Other
YOUR BUSINESS POSITION Wife's Business YOUR BUSINESS POSITION

,.. 2 IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA .... 2 IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE YOUR PRO RATA
SHARE OF THE GROSS INCOME TO THE ENTITYITRUST) SHARE OF THE GROSS INCOME TO THE ENTITYITRUST)

I2Sl $0 - $499 D $10,001 - $100,000 D $0 - $499 D $10,001 - $100,000

D $500 - $1,000 DOVER $100,000 D $500 - $1,000 DOVER $100,000
D $1,001 - $10,000 D $1,001 - $10,000
,.. 3 LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF ... 3 LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF
INCOME OF $10,000 OR MORE (Att~ch ~ ,;~para!~ sh<;e! d n~c~'SJryl INCOME OF $10,000 OR MORE (Attach a .~para!e sheet ,t nCCCS5ar\ 1

.... 4 INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD BY THE .... 4 INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD BY THE
BUSINESS ENTITY OR TRUST BUSINESS ENTITY OR TRUST
Check one box: Check one box:
DINVESTMENT D REAL PROPERTY DINVESTMENT D REAL PROPERTY

Name of Business Entity Q!: Name of Business Entity Q!:

Street Address or Assessor's Parcel Number of Real Property Street Address or Assessor's Parcel Number of Real Property

Description of Business Activity Q!: DeScription of Business Activity Q!:

City or Other Precise Location of Real Property City or Other Precise Location of Real Property

FAIR MARKET VALUE IF APPLICABLE, LIST DATE: FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
D $2,000 - $10,000 D $2,000 - $10,000
D $10,001 - $100,000 D $10,001 - $100,000 ----.1---1 10 ----.1----.1.JJL
D $100,001 - $1,000,000 ACQUIRED DISPOSED D $100,001 - $1,000,000 ACQUIRED DISPOSED
DOver $1,000,000 DOver $1,000,000

NATURE OF INTEREST NATURE OF INTEREST

D Property Ownership/Deed of Trust D Siock D Partnership D Property Ownership/Deed of Trust D Stock o Partnership
D Leasehold D Olher _ _ _ _ _ _ _ _ __ D Leasehold D Olher _ _ _ _ _ _ _ __
Yrs. remaining Yrs. remaining
D Check box if additional schedules reporting investments or real property D Check box if additional schedules reporting investments or real property
are attached are attached

Comments: Closed Business in January FPPC Form 700 (2010/2011) Sch. A-2
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.goY
 CALIFORNIA FORM 700
SCHEDULE B FAIR POLITICAL PRACTICES COMMISSION

Name
Interests in Real Property
(Including Rental Income) Jeff Smith

III- STREET ADDRESS OR PRECISE LOCATION III- STREET ADDRESS OR PRECISE LOCATION

14410 Lakeshore Dr 14420 Lakeshore Dr

CllY CllY

Clearlake CA 95422 Clearlake CA 95422

FAIR MARKET VALUE IF APPLICABLE, LIST DATE: FAIR MARKET VALUE IF APPLICABLE, LIST DATE:
o $2,000 - $10,000 o $2,000 - $10,000
I8J $10,001 - $100,000 ~~.JJ!.. ~~.JJ!.. 0$10,001 - $100,000 ~~.JJ!.. ~~.JJ!..
o $100,001 - $1,000,000 ACQUIRED DISPOSED I8J $100,001 - $1,000,000 ACQUIRED DISPOSED
DOver $1,000,000 DOver $1,000,000

NATURE OF INTEREST NATURE OF INTEREST

~ Ownership/Deed of Trust o Easement [gI Ownership/Deed of Trust o Easement
D Leasehold - __- - : - c - -
Yrs. remaining
0----,-,-----
Other
o Leasehold - __- - : - c - -
Yrs. remaining
0 - - - Other
-:----
IF RENTAL PROPERlY, GROSS INCOME RECEIVED IF RENTAL PROPERTY. GROSS INCOME RECEIVED

~ $0 - $499 0 $500 - $1,000 0 $1,001 - $10,000 o $0 - $499 0 $500 - $1,000 0 $1,001 - $10,000
0$10,001 - $100,000 0 OVER $100,000 I8J $10,001 - $100,000 DOVER $100,000

SOURCES OF RENTAL INCOME: If you own a 10% or greater SOURCES OF RENTAL INCOME: If you own a 10% or greater
interest, list the name of each tenant that is a single source of interest, list the name of each tenant that is a single source of
income of $10,000 or more. income of $10,000 or more.

* You are not required to report loans from commercial lending institutions made in the lender's regular course
of business on terms available to members of the public without regard to your official status. Personal loans
and loans received not in a lender's regular course of business must be disclosed as follows:

NAME OF LENDER* NAME OF LENDER*

ADDRESS (Business Address Acceptable) ADDRESS (Business Address Acceptable)

BUSINESS ACTIVITY, IF ANY, OF LENDER BUSINESS ACTIVITY, IF ANY, OF LENDER

INTEREST RATE TERM (Months/Years) INTEREST RATE TERM (Months/Years)

----,% D None ----,% D None

HIGHEST BALANCE DURING REPORTING PERIOD HIGHEST BALANCE DURING REPORTING PERIOD
o $500 - $1,000 0$1,001 - $10,000 0$500 - $1,000 0 $1,001 - $10,000
0$10,001 - $100,000 DOVER $100,000 o $10,001 - $100,000 DOVER $100,000

D Guarantor, if applicable o Guarantor, if applicable

Commenw: ____________________________________________________________________________________
FPPC Form 700 (2010/2011) Sch. B
FPPC TolI·Free Helpline: 866/275·3772 www.fppc.ca.goY
, ,

CALIFORNIA FORM 700

SCHEDULE B FAIR POLITICAL PRACTICES COMMISSION

Interests in Real Property Name

(Including Rental Income) Jeff Smith

... STREET ADDRESS OR PRECISE LOCATION r-~:-~ST=R~E::E::T-:A':D~D~RE:::S~S:-O~R~P~R~EC~'~S~E:L~O~CA~T~10~N::=======

14430 Lakeshore Dr
CITY CITY

Clearlake
FAIR MARKET VALUE
D $2,000 - $10,000
181 $10,001 - $100,000
D $100,001 - $1,000,000
DOver $1,000,000
CA 95422
IF APPLICABLE, LIST DATE: FAIR MARKET VALUE IF APPLICABLE. LIST DATE:
D $2,000 - $10,000
----1----1~ ----1----1~ D $10,001 - $100,000 ----1----1~ ----1----1~
ACQUIRED DISPOSED D $100,001 - $1,000,000 ACQUIRED DISPOSED
DOver $1,000,000

NATURE OF INTEREST NATURE OF INTEREST

181 Ownership/Deed of Trust o Easement o OWnership/Deed of Trust o Easement
o Leasehold - - , , - - - , , - - - D - - - ,Other
------ o leasehold _ _ _ _ __
D--- :----
Yrs. remaining Yrs. remaining Other

IF RENTAL PROPERTY, GROSS INCOME RECEIVED IF RENTAL PROPERTY, GROSS INCOME RECEIVED

D $0 - $499 D $500 - $1,000 181 $1,001 - $10,000 D $0 - $499 D $500 - $1,000 D $1,001 - $10,000
D $10,001 - $100,000 DOVER $100,000 D $10,001 - $100,000 DOVER $100,000

SOURCES OF RENTAL INCOME: If you own a 10% or greater SOURCES OF RENTAL INCOME: If you own a 10% or greater
interest, list the name of each tenant that is a single source of interest, Jist the name of each tenant that is a single source of
income of $10,000 or more. income of $10,000 or more.

* You are not required to report loans from commercial lending institutions made in the lender's regular course
of business on terms available to members of the public without regard to your official status, Personal loans
and loans received not in a lender's regular course of business must be disclosed as follows:

NAME OF LENDER" NAME OF LENDER"

ADDRESS (Business Address Acceptable) ADDRESS (Business Address Acceptable)

BUSINESS ACTIVITY, IF ANY, OF LENDER BUSINESS ACTIVITY, IF ANY, OF LENDER

INTEREST RATE TERM (MonthslYears) INTEREST RATE TERM (MonthsIYears)

----,% D None ----,% D None

HIGHEST BALANCE DURING REPORTING PERIOD HIGHEST BALANCE DURING REPORTING PERIOD
D $500 - $1,000 D $1,001 - $10,000 D $500 - $1,000 D $1,001 - $10,000
D $10,001 - $100,000 DOVER $100,000 D $10,001 - $100,000 DOVER $100,000

D Guarantor, if applicable D Guarantor, if applicable

Commenw: ______________________________________________________________________________
FPPC Form 700 (2010/2011) Sch, B
FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov