---

CALIFORNIA FORM
fAIR POLITICAL tRACrlCr.:S
700
COMMISSION
STATEMENT OF ECONOMIC INTERESTS
COVER PAGE
A Public DOCUlnent
Please type or print in ink.

(FIRST) (MIDDLE)
NAME (LAST}

De La Pena William Charles ( 323 ) 728 5500

CITY STATE ZiP CODE OPTIONAL FAX E-M.L,IL ADDRESS
MAILING ADDRESS STREET
(May use business address)

2446 W. Whittier Blvd. Montebello CA 90640

1. Office, Agency, or Court 4. Schedule Summary

Name of Office, Agency, or Court ... Total number of pages 10
including this cover page: _
University of California
Division, Board, District if applicable: ~ Check applicable schedules or "No reportable
interests. "
Board of Regents
I have disclosed interests on one or more of the
Your Position: attached schedules
Regent Schedule A-1 0 Yes - schedule attached
~ If filing for multiple positions, list additional agency(ies)/ Investments (Less than 10% Ownership)
position(s): (Attach a separate sheet if necessary)
Schedule A-2 IRl Yes - schedule attached
Investments (10% or greater Ownersh(o)
Agency
Schedule B IRl Yes - schedule attached
Position: -,--- _ Real Property

Schedule C I8l Yes - schedule attached

Income, Loans, & Business Positions (Income Other than Gifts
2. Jurisdiction of Office (Check at least one box) and Travel Payments)

!gj State Schedule D 0 Yes - schedule attached

o County of ---------------- Income - Gifts

o City of _ Schedule E n Yes - schedule attached

o Multi-County ---------------- Income - Gifts - Travel Payments

-or-
LJ Other ------------------
o No reportable interests on any schedule
3. Type of Statement (Check at least one box)

o Assuming Office/Initial Date -----.J-----.J__

5. Verification
IX! Annual: The period covered is January' 1. 2008.
I have used, all reasonable diligence in preparing this
through December 31, 2008.
statement I have reviewed this statement and to the best
-or- OhflY knowledge the information contained herein and in any
O The period covered is -----.J-----.J__ , through attached schedules is true and complete.
December 31. 2008.
I certify under penalty of perjury under the laws of the State
LJ Leaving Office Date Left: -----.J-----.J-- of California that the foregoing is true and correct.
(Check one)
o The period covered is January 1. 2008. through the
date of leaving office. Date Signed 3/26f2009
/7 {month. day. ye8r}~
-or-
o The f::-eriodcovered is f-----.J , through
/ /.~.~/ // --//>'::"/
Signature > // - ~ C L-"- C/' i>.t;:'-i/ "~ A
- (FHe the originally signed statem"ent "./lith your filing officiaL)

FPPC Form 700 (2008/2009)

FPPC Toil-Free Helpline: 866/ASK-FPPC www-fppc.ca.gov
 ,--- .. " ... '..;,,; •..• :c;';:; .••,~.

SCHEDULE A-2 ~CAUFORl\I'A

FAIR POUTICAL PRACTICEStQr"'llfsiIO~~:!~
FORM7ffJ :'
Investments, Income, and Assets .:.. . :: .:~_ -:< :."':.:::;) ~; ~\.,_,'..~_-·..·;_::L,-;~:·'";r:--(,;, .. ; •• i'_:.:':£~'·,,·::t:

of Business Entities/Trusts
I Name

(Ownership Interest is 10% or Greater) I William C. De La Peril

De La Peiia Eye Clinic

Name
I MED-lASER SURGICAL CENTER
Name
2446 W. Whittier Blvd., Montebello, CA 90640 2445 W. Whittier Blvd., #100; Montebello, CA 90640
Address Address
Check one
oTrust, go to 2 eg Business Entity, complete the box, then go to 2
Check
o
one
Trust, go to 2 !&l Business Entity, complete rhe box, then g

GENERAL DESCRIPTION OF BUSINESS ACTIVITY ',GENERAL .OESCRIPTION OF BUSINESS ACTIVrr;'

Ophthalmology Practice
FAIR MARKET VALUE IF APPLICABLE. LIST DATE:
o $2,000 ' $10,000
__ 1.._-.1 08
o
FAIR MARKET VALUE
S2.000, $10.000
IF APPLICABLE. LIST DATE

0$10.001 - $100.000 0$10,001 - $100.000 ---"---1~

o S100.001 - 51.000.000 DISPOSED o $100.001 ' $1.000.000 ;'COUIRED
'~Over 51.000.000 [81 Over S1.000.000

NATURE OF INVESTMENT NATURE OF INVESTMENT

~ Sole Proprietorship 0 Partnership 0 _ !8l Sole Proprie!Orsllip 0 Partnership 0 _
Owne!';IP·resident/PhysiCIan
. Qlh~r
YOUR BUSINESS POSITION YOUR BUSINESS pOSrnON OwnerlPresidentlSurg':>n

o SO - $499 o $10.001 - $100,000 o SO, $499 o S10,001 ' $100,000

05500, S1.000 18l OVER S100.000 0$500, S1.000 I&l
o $1.001 - $10.000 o $1,001 ' $10.000
OVER $100.000

• 3: tiS T THE t.JJ\t ..'F {)F ["fl.CH RrpORTf~B! ~: 5ri\iGt [ SOURCr OF ~:: liST THE NAME OF EACH HEPORlABLE sir. GtE SOURCE or
INCO~E OF $10.0.~O OR MORE ,'''",,,, ,+~,
...'" .
~,."'!" ",,0..·.'',;
INCOM.EOF S1,M!lO.9R..MOi'!E (''!.!<:~' ''''i'''~''''''~'f'':>!;'~VI
see attached

~ ~ INVf$lt.llC'~f5 M'il) !'HERESTS Ir~ REAL PROP['?F HFUl B'{ HlE ... 4. I,WESTMEt-lTSMm 1T-J1EHCSTS IN REAL PROPERTY HElD~THE
BUSlr~ESS ENTITY OR TRUST BUSI~E:~SEr~r\TY o~ TRlJ~T .
Check one box: Check one box:
o INVESTMENT 18l REAL PROPERTY o INVESTMENT ~ REAL PROPERTY

2446 W. Whittier Blvd. 2445 W. Whittier Blvd:, #100

Name of Business Entity ill 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

Montebello, CA 90640 Montebello, CA 90640

Description of Business Activity ill Description of Business Activity Q[
City or Other Precise Location of Real Property City W, plher Precise Location of Real Property

FAIR MARKET VALUE fF APPLICABLE. LIST DATE: FAIR MARKET VALUE IF APPLICABLE. LIST DATE:
o 52,000 - S10,000 o $2.000 - $10.000
0$10,001 ' $100.000 ---1---1 08 --,--'!..8 o $10.001 - $100.000 ---1---1 08 --'---1 08
[)
~
$100.001,
Over $1.000.000
$1.000.000 ACQUIRED DISPOSED o S100.001 ' $1,000.000 ACQUiRED DISPOSED
~ Over 51.000.000

NATURE OF INTEREST
o Property Ownership/Deed of Trust o Stock o Partnership
NATURE
o Property
OF INTEREST
Ownership/Deed of Trust o StO"...K o Partnership

3 0 Other
~ Leasehold
. Yrs. remaining
_
t8l Leasehold
Yrs,
3
remaining
o Other ----------

18l. Check box if additional schedules reporting investments or real property !&l Check box ITadditional schedules reporting investments or real property
are attached are attached

Comments: FPPC Form 700 (200S/ZOO9)

Sch, A-2
FPPC Toll-Free Helpline: 866!ASK·FPPC www.fppc.ca.gov
 SCHEDULE A-2
DE LA PENA EYE CLINIC
ADDITIONAL LEASEHOLD INVESTMENTS

139 S. ALVARADO STREET

LOS ANGELES, CA 92257

FAIR MARKET VALUE $100,001 - 1,000,000

LEASEHOLD FOR 4 YEARS

2715 E. FLORENCE
HUNTINGTON PARK, CA 90255

FAIR MARKET VALUE $100,001 - 1,000,000

LEASEHOLD FOR 4 YEARS

 SCHEDULE A-2

INCOME SOURCES OVER $10,000

DE LA PENA EYE CLINIC

BLUE CROSS
BELLA VISTA
CARE FIRST
MEDICARE
MEDICAL
UNIVERSAL CARE
A. DE LA PENA, MEDICAL GROUP, INC
SAN MIGUEL, IPA
ALTAMED
MOLINA HEALTH CARE
ASSOCIATION OF HISP Acl\JICPHYSICIANS

MED-LASER SURGICAL CENTER

MEDICARE
MEDICAL
BLUE CROSS
ST. LUCIA EYE CENTER
A. DE LA PENA, MEDICAL GROUP, INC
SAN MIGUEL, IPA
ALTAMED
 SCHEDULE A"2 CALIFORNIA FORM '1OOi~
Investments, Income, and Assets FAIR ?QUT1CAL PRf.CTfCES COMMISSIOtt,~';

of Business EntitieslTrusts I
~,,'d'>!:'
Name

(Ownership Interest is 10% or Greater) ! William C. De La Pena

.. 1, BUSINESS ErmTY OR TRUST

De La Pena Family Trust dated 11~6/01

Name
De La Pena Family Trust dated 11/26/01
Name
2446 W. Whittier Blvd., Montebello, CA 90640
Address
2446 W. Whittier Blvd., Montebello, CA 90640
Address
Check one
l&! Trust, go to 2 o B'!siness Entity, complete the box, then go to 2
Check one
~ Trust, go to 2 0 Business Entity, complete the box, then go to 2

GENERAL DESCRIPTION OF BUSINESS ACTIVITY

GENERAL DESCRIPTION OF SUSINESS ACTIVITY

FAIR MARKET VALUE IF APPLICABLE LIST DATE: FAIR MARK.."'T VALUE

'0 $2,000 - $10.000 IF APPLICABLE UST DATE'
051,000 - $10,000
0$10,001
0$100,001
- $100,000
- $1,000,000
---...J ---.I 08
ACQUIRED
---1---108
DISPOSED
o $10,001 . $100,000 ---.J---.108 ---.J---.J08
0$100,001. - $1,000,000 ACQUIRED DISPOSED
DOver $1,000,000
DOver S1,000.000

NATURE OF INVESTMENT
o Sole Proprietorship 0 Partnership 0 _
Other
i YOUR BUSINESS POSITION _ Other

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

o $500 - $1,000 !8l OVER $100,000
0$0
0$500
- $499
- $1,000
0$10,001
!&l OVER
- $100,000

0$1,001 - $10,000 o $1,001 - $10,000

$'100,000

~ ~ LIST rHEr·Jht-./~[ OF [f ..(~H ~fPORTAP.LE Slf·';G1.f 'SOURCE Of

,., ? I,:sr TilF ~;M.1For- U.CH R!';JOfH/\BU: SI:'JGI f SOURCE or
INCOME OF S10,OOO OR MORE '"',,," " ":,'-". , ,,,,,,,,. C"""",,,~,
INCOME OF S1G,OOO OR MORE f"·'."h. '.<;: ••" .,,.,,, ;lr"",",'"";1
Med-Laser Surgical Center. Goldex Jewelry
De La Pena Eye Clinic; A. De La Pena, A Medical
Group, Inc .

., 4 IWJeST:.1HHS AND INTERESTS IN REAL PROPERTY HELD IE THE

BUSINESS ENTITY OR 'TRUST
.. .: 1~;Vf.SiM£'Nrs AND INTERESTS I~J REAL PROPERTY HELD .f2Y.THE· ;
BUSINESS ENTITY ORl RUS-r
Check one box:

o INVESTMENT !8J REAL PROPERTY o

Check one box:

INVESTMENT Qg REAL PROPERTY

2445 W. Whittier Blvd. 2446 W. Whittier Blvd.

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

Montebello, CA 90640 Montebello, CA 90640

Description of Business Activity Q(
Description of Business Activity Q(
'City or Other Precise Location of Real Property
City o't~Other Precise Location of Real Property

F,AJR MARKET VALUE

o S2,000 - S10,000
IF APPLICABLE, LIST DATE: FAIR MARKET
o
VALUE
$2,000 - $10,000
IF APPLICABLE, LIST DATE:

U S10,001
~
- $100,000
51oo,O{), - 51,000,000
---.J---1 08
ACQUIRED
---1--'p'8
DISPOSED
o $10,001 - $100,000 --.:..J ---.I 08 ---1---1 08
~ $100,001 - $1,000,000 ACQUIRED DISPOSED
00 Ova 51,000,GOO
DOver $1,000,000

~TURE OF INTEREST
NATURE OF INTEREST
. l P~i Ownership!Deed of Trust o Stocl< o Partnership o Property OwnershipfDeed of Trust o Stock o Partnership

o Q-,ner - _
o
o LeaS~hold Yrs, remaining
Other _

u~ box ~ ~d'!al
ere G1.tacteo
schedules reporting investments or real property
~ Check box if additional schedules reporting investments or real. property
are atiached

Comments: FPPC Form 700 (200812009) Sch. A-2

FPPC Toll-Free Helpline: 8661ASK-FPPC www.fppc.ca.gov
 SCHEDULE A-2

DE LA PENA FAMIL Y TRUST DATED 11/26/2001

ADDITIONAL INVESTMENTS

2428 W. WHITTIER BLVD.

MONTEBELLO, CA 90640

TENANT: HAMID MALAKOOTI, MD - $10,001-100,000

FAIR MARKET VALUE $100,001 - 1,000,000

139 S. ALVARADO STREET

LOS ANGELES, CA 90057

TENANT: DE LA PENA EYE CLINIC - $10,001 -100,000

FAIR MARKET VALUE $100,001-1,000,000

2438 W. WHITTIER BLVD.

MONTEBELLO, CA 90640

. TENANT: DE LA PENA EYE CLINIC

FAIR MARKET VALUE $1,001-10,000

2438 Yz W. WHITTIER BLVD.

MONTEBELLO, CA 90640

TENANT: Fernando Vera $1,000 - $10,000

FAIR MARKET VALUE $100,001 - 1,000,000

 SCHEDULE A-2
SECTION 4

DE LA PENA FAMILY TRUST DATED 1112612001

ADDITIONAL INVESTMENTS
PG.2

2715 E. FLORENCE
HUNTINGTON PARK, CA 90255

TENANT: DE LA PENA EYE CLINIC - $10,001-100,000

FAIR MARKET VALUE $100,001 - 1,000,000

7145 STAFFORD
HUNTINGTON PARK, CA 90255

TENANT: Uriel Nava $10,001 - $100,000

FAIRMARKETVALUE$100,001-1,000,000

2430 W. WIDTTIERBLVD.
MONTEBELLO, CA 90640

TENANT: NIA

FAIR MARKET VALUE $100,001-1,000,000

2434 W. WHITTIER BL YD.

MONTEBELLO, CA 90640

TENANT: NIA

FAIR MARKET VALUE $100,001 - 1,000,000

 SCHEDULE A-2 CALIFORNIA FORM
FAIR POllnCA!.
700
PRACTICES COMMiSSION
Investments, Income, and Assets
Name
of Business Entities/Trusts
(Ownership Interest is 10% or Greater) William C. De La Pefia

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

De La Pena Family Trust dated 11/26/01

Name Name
2446 W. Whittier Blvd., Montebello, CA 90640
Address Address
Check one Check one
~ Trust. go [0 2 o Business Entity. complete the box. then go to 2 oTrust. go to 2 o Business Entity, complete the box, then go to 2

; GENER,i;.L DESCRiPTiON OF BUSiNESS .A.GTIViTY

, FAIR M,"-.RKET \1.ll,LUE IF A.PPLICABLE. LIST DATE

----------_ .•._._------
FAiR MJ..RVET 'VAlUE
i0 S2.000 - 510.000
__ 1__ 108
o S2.DOI) . S 10.Q(H:"
0$10.001 - $100.000 ---.J.---..l 08 D $10.00 1 . SH)O GDO ,08
05100.001 - $1.000.000 ACQUIRED D!SPOSED o $iC!0r.JCf $10DL!0CC .:!:o,(.Cr)JPED
DOver S1.000.000 o O'.l'~r $ ~.DOG.DOG

, N.ATURE OF tNvESTrvlENT NATURE. C,F it'J;JESTMENT

~
0 Soie
.
Proprietorship 0 Partnership 0 -,-
Other
_ n Sote Prop!tt-!t~)fShip n P8;me{~.hlc
[] ,,-,-
Ii
ii YOUR BUSINESS POSITION _

.. 2. IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE VOUR PRO RATA • 2. IDENTIFY THE GROSS INCOME RECEIVED (lNCWOE YOUR PRO RATA
SHARE OF THE GROSS INCOME IQ THE ENTrrYfTRUSn SHARE OF THE GROSS INCOME 12 THE ENTITYITRUSn

I ! so - 8499 !Xl $10,001 - S100.000 050 - $499 0$10.001 - $100.000

n S500 - SI :000 DOVER $100.000 05500 - 51.000 DOVER 5100.000
o 51.001 - $10.000 051,001 - $10.000

3. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF .. 3. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE or
INCOME OF S10,GOO OR MORE i.;~."" , .."....' it" *..
, ,".,."".~,.i
,I INCOME OF S10.000 OR MORE I,>tt.",n " '4'P...~,•• h ... : ',,""' ... -..rf'
Mr. Guindi

.. 4. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD BY THE ~ 4, INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD §.Y. THE
BUSINESS ENTITV OR TRUST BUSINESS ENTITY OR TRUST
Check one box: Check one box:
o iNVESTMENT f8J REAL PROPERTY o INVESTMENT o REAL PROPERTY

1760 Avenida del Mundo

Name of 'Business Entity ill Name of Business Entity ill
Street )I.,ddress or p.ssessor's Parcel Number of Real Property Street Address or Assessor's Parcel Number of Real Property

Coronado, CA 92118
Description of Business Activity Q[ Description of Business A.ctivity ill
City or Other Precise Location of Rea! Property City or~Other Precise Location of Reai Property

F.",IR M."'.RKET VALUE IF ,A'pPUC,A.BLE. UST DATE: FAIR MARf<ET VALUE iF APPLlC."'.BLE. liST D,oTE:
L.J S2.000 - $10.000 CJ $2.000 - S10,000
o $10,001 - $100.000 ---.J---.J 08 ---.J __ p8 o $10.001 - S100.000 ---.J_i 08 ---.J ---.J 08
n 5100.001 - 51.000.000 ;CQUIRED DISPOSED 05100,001 - $1.000,000 ACQUIRED DiSPOSED
[gJ Over $1,000.000 DOver S"l.ooo.ooo
NATURE OF iNTEREST ~l."'TURE OF INTEREST
f8J Property Ownership/Deed of Trust o Stock o Partnership o Property Ownership/Deed of Trust o Stock U Partnership

n Leasehold Yrs. remaining

CJ Other ~ __
o Leasehofd
·y'rs. rS:ri8inir,g
o Otrler

o Check box if additional

are attached
schedules reporting investments or real Dropeny o Check bo:< If addit!onaf schedules
are attached
reporting investments or rea! property

Comments: _ FPPC Form 700 (ZOO8/2009) Sch. A-Z

FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov
 SCHEDULE C CALIFORNIA FORM 700
Income, Loans, & Business FAIP. POLmCAl PRACTICES COMMISSION

Name
Positions
(Other than Gifts and Travel Payments) William C. De La Pena

• .'
NAME OF SOURCE OF INCOME
NAME OF SOURCE OF INCOME

De La Pena Eye Clinic Med-Laser Surgical Center

ADDRESS
ADDRESS

2446 W. Whittier Blvd., Montebello, CA 90640 2445 W. Whittier Blvd., #100; Montebello, CA 90640
BUSINESS ACTIVITY. IF ANY OF SOURCE
BUSINESS ACTIVITY. IF ANY. OF SOURCE

Ophthalmology Practice Ambulatory surgical center

YOUR BUSINESS POSITION
YOUR BUSINESS POSITION

Owner/President/Physician Owner/President/Surgeon
GROSS INCOME RECEIVED
GROSS INCOME RECEIVED
o 5500 - 51.000 0 $1.001 - 510.000
o S500 - $1.000 0 51.001 - S10.000
0510.001 - S100.QOO ~ OVER S100.000
0$10.001 - S100.000 ~ OVER $100.000

CONSIDERA.TION FOR WHICH INCOME WAS RECEIVED

CONSIDERATION FOR WHICH INCOME WAS RECEIVED
~ Salary 0 Spouse's Of registered domestic partner's income
o Salary n Spouse's or registered domestic partner's income
o Loan repayment o Loan repayment

o Sale of o SaJe of
(Property, caT.-boat, etc.) (Property. car, boac. etc.)

i j Commission or tJ Rental lncome. list each source of 510,000 or more o Commission or 0 Rental Income. fist each source of $70.000 or more

U Other Qg Other Owner's draw/Director's fee

{Describe) (Describe]

.. 2. LOANS RECEIVED OR OUTSTANOIToJG DURING THE REPORTING PERIOD

* You are not required to report loans from commercial lending institutions,' or any indebtedness created as part
of a retail installment or credit card transaction, made in the lender's regular course of business on terms
available to members of th'e 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' INTEREST RATE TERM (MonthsiYears)

Self to De La Pen a Eye Clinic _____ % [gj None

.A.DDRESS

2446 W. Whittier Blvd., Montebello, CA 90640 SECURITY FOR LOA.N

BUSINESS ACTIVITY IF ANY OF LENDER Qg None 0 Personal residence

Administration/Physician
[] Rear Property Street addnE-'.';5
HIGHEST BALA.NCE DURING REPORTiNG PERIOD

[J $500 - $1.000
City
D $1.001 - S10.000
o Guarantor --- _
U $10.001 - $100.000

[gj OVER S100.000

o Other {Describe}

Comments:

FPPC Form 700 (2008/2009) Sch. C

FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov
 SCHEDULE C
Income, Loans, & Business
CALIFORNIA FORM
FAIR POLl!lCAl
70
PRACTICES cm'::MISSION

Positions
(Other than Gifts and Travel Payments)
- -
William C. De La Pena
•
NAME OF SOURCE OF INCOME •
NAME OF SOURCE OF INCOME
De La Pena Eye Clinic
.ADDRESS YMCA
ADDRESS
2446 W. Whittier Blvd., Montebello, CA 90640
BUSINESS A.CTIVITY. IF ANY. OF SOURCE 12510 E. Hadley, Whittier, CA 90601
BUSINESS ACTIVITY, IF ANY. OF SOURCE
Ophthalmology Practice
YOUR BUSINESS POSITION Community resource
YOUR BUSINESS POSITiON
Book keeping/Managerial
GROSS INCOME RECEIVED
Aerobic/Group Exercise Instructor
o 5500 - $1.000 0 $1001 _ S10.000 GROSS INCOME RECEIVED

I8J $10.001 - $100.000 0 OVER S100.000 0$500 - $1.0.00

fZ1 $1,001 - 510,000
o $10,001 - S100,000
DOVER S100.000
CONS!DERATION FOR VVHICH INCOME WAS RECEIVED

o Salary cg) Spouse's or registered domestic partner's income CONSIDERAT!ON FOR WHICH INCOME W,A,S RECEIVED

o Loan repayment o Salary 0 Spouse's or registered domestic partner's income

o Sale of -::;:=-:-_--:- _
o Loen repayment

(Property. car,. boal. etc) o Sale of _

[] Commission or
o Rental income. list each source of $10,000 or more
o
(Property' car, boal, etc.)

Commission Or
o Rental Income. iist each Source of 510,000 or more

n Other (Describej

o Other (Describe)

... '.WlOjMi#N#,',Jji,liiMWillMi,jiM@§iUii;J£ig·I;'M###;1[-1'
* You are not required to report loans from commercial lending institutions, or any indebtedness created as part
of a retail installment or credit card transaction, made in the/ender'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:
N,A.ME OF LENDER"

!NTEREST RATE TERM (MonthslYears)

Self to Med-Laser Surgical Center
ADDRESS
----% I&J None
2445 W. Whittier BlVd., #100; Montebello, CA 90640 SECURITY FOR LOAN
BUSINESS ACTiVITY. IF ANY. OF LENDER
I&J None 0 Personal residence
Administration/Surgeon
HIGHEST BALANCE DURING REPORTING PERIOD EJ' Peal Property Sireet address
o 5500 - 51.000

U S1.0Q1 - $10.000
City

Ll 510.001 - $100.000 o Guarentcf ___

I&J OVER S100.000

o Other (Describej

Comments:

FPPC Form 700 (2008/2009) Sch. C

FPPC Toll-Free Helpline: 866/ASK-FPPC WWW.fppc.ca.gov