Bloom Richard Hershel 1
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. , [E ©JEtJlnMIIEI~ CALIFORNIA FORM 700 STATEMENT OF ECONOMIC INTERESTS Received , FAJR pu!"!1'CAt,, ~RAeJ1C:ES COi;,Hi,USSmn MAY O"'1"~M5"Y AMENDMENT COVER PAGE . ~ P1esse fyp8 or print In Ink. NAME OF AlER (lAST) (FIRST) Bloom Richard Hershel 1. Office, Agency, or Court Agency Name (Do not use acronyms) California State Assembly Di~slon, Soan!, Department DIstrict ~ appfocable Your Position Assembly District 50 Assemblymember • If filina tor muffiple posffions, I~t below or on an ettachment (Do not use acronyms) Agenq: _________________________________ 2. Jurisdiction of Office (Check .tleaM one box) :? ~:: Ii'I State Judge or Court Commissioner (Statewide Jurisdiction):: ,:, ~ =- o ---, -- , o Multl-County ______________ o County m ' , Oatym ______________ o Other _____________________--'-'-- __'--- 3. Type of Statement (Check.t le ..t one box) Ii'I Annual: The peliod covered ~ Jenuary I, 2014, throtl!lh o Leaving OffIce: Date Left ---1---1___ _ December 31, 2014. (Check one) -or- The period covered Is ---1---1___ ~ throtl!lh o The period covered ~ January I, 2014, throtl!lh the date m December 31, 2014. leaving office. o Assuming Office: Date assumed ---1---1___ _ o The period covered ~ ---1---1____ through the date of lea~ng office. o Candidate: Election year ______ and office saught, ~ different than Pat 1: _______________ 4, Schedule Summary Check applicable schedules or "None. " ~ Total number of pages Including this cover page: _2__ _ o Schedule A·l • Investments - schedule attached o Schedule C • Income, Loans, & Business Posffions - schedule attached o Schedule A·2 • Investments - schedule attached IZI Schedule 0 • Income - Gifts - schedule attached o Schedule B • Real Property - schedule attached o Schedule E • Income - Gifts - Travel Payments - schedule attached -or· o None· No rapoJtabf8 interasts on eny scheoufe ⁴⁾† I certify under penalty of perjury under the laws of tho State of California that Oate Signed 05/07/2015 Signatur ⁾† (m<nIh. "" "'" FPPC Advlce Email: [email protected] FPPCTolI·Free Helpline: 866/275-3772 www./ppc.ca.gov , . f CALIFORNIA FORM 700 SCHEDULE D FAIR POliTICAl. PRACllC!,;' CvM'o'ItS.5:('l~J; - Gifts AMENDMENT 2D151;li1-8 Ph i:3o .... NAME OF SOURCE (Not an Acronym) .... NAME OF SOURCE (Not an Acronym) Callfomla Democratic Party ADDRESS (Business Address Acceptab~) ADDRESS (BuslneS$ Addre~s Acceptable) 1830 Ninth Street. Sacramento. CA 95814 BUSINESS ACnvlTY. IF ANY, OF SOURCE BUSINESS ACTtVlTY, IF ANY. OF SOURCE Campaign DATE (mmlddlyy) VALUE DESCRIPTION OF GIFT(5) DESCRIPTION OF GIFT(S) Food and Beverage ---1---1_ $..$__ _ ---1---1_ ... ____ ---1---1__ .., ___ _ ---1---1__ ..$ ___ _ .... NAME OF SOURCE (Not an Acronym) .... NAME OF SOURCE (Not an Acronym) ADDRESS (Business AddreS5 Acceptabl9) ADDRESS (8us/ness Addre~s Acceptable) BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE DATE (mmIddJyy) VALUE DESCRIPTION OF OIFT(S) DATE (mmlddlyy) VALUE DESCRIPTION OF GIFT(S) ---1---1_ ..$ ___ _ ---1---1_ $..$__ _ ---1---1_ 0.$ ____ ---1---1__ .., ___ _ $ ---1---1_ 0.$ ____ .... NAME OF SOURCE (Not an Acronym) Filer's Verification Print Nama Richard Bloom ADDRESS (Business Address Accepmble) Office, Agency or Court Callfomla State Assembly BUSINESS ACTIVITY, IF ANY, OF SOURCE Statemant Typa ~ 201412015 Annua( D Assuming D Leaving DCandldale DATE (mmlddlyy) VALUE DESCRIPTION OF 0IFT(9) D-r;;rAnnual I have used all reasonable diligence In preparing this statement. I have ---1---1__ ..$ ___ _ revtewed this statement and to the best of my knowledge the Information contaIned herein and In any attached sdledules Is true and complete. ---1---1__ >-$ ____ I certify under penalty of perjury under the laws of the State of California that the foregoing Is true and correct ---1---1__ ..$ ___ _ Oat. Signed _____----;;:!!Q~5f'IQ~7~12~Q!:i1"'5'-------- (c)(1) ⁾† Flier's Signature Commanta: ______________________________________________________________________________ FPPC Form 700 (2014/2015) 5th. 0 FPPC Advice Email: [email protected] FPPC Toll-Free Helpnn.: 866/275-3n2 www.fppc.ca.gov . , , , ' " . -- o lE rm fE OIYl [E Date Initial i CALIFORNIA FORM 700 STATEMENT OF ECONOMIC INTEREST FEB 26om~e. fA!R POlmCA'L PRACl1C£S C:OMr~ssmu A PUBLIC DOCUMENT COVER PAGE By fW± Please type or print in Ink. NAME OF RLER (lAST) (RRST) ("'DOLE) Bloom Richard Hershel 1. Office, Agency, or Court Agency Name (Do nol use acronyms) California State Assembly Divisi011, Board, Departmen~ District, il applicable Your Position District 50 Assemblymember ~ If filing for multiple positions, list below or on an attachmenL (Do nol use acronyms) Agoocy: _____________________________________ o 2, Jurisdiction of Office (Check at least ona box) en c III State o Judge or Court Commissioner (Stalewide Jurisdlcti011) o Multi-County ______________ o County of _______________ Ornher ____________________________ OC~o/---------------------------- 3. Type of Statement (Check st lessl one box) III Annual: The period covered ~ January 1, 2014, through o Leaving OffIce: Date Left -----1-----1.______ _ December 31, 2014. (Check one) -or· The period covered is -----1-----1______ ~ through o The pefiod covered is January 1, 2014, through the dale of December 31, 2014. leaving office. o Assuming Office: Date assumed -----1-----1______ _ o The period covered Is -----1-----1______ ~ through the dale 01 leaving office. o Candidate: Election year ___________ and office sought, if different than Part 1: _____________________________ 4. Schedule Summary Check applicable schedules or "None. " ~ Total number of pages Including this cover page: I 5" III Schedule A·1 • Investmenls - schedule attached III Schedule C • Income, wans, & Business Positions - schedule attached o Schedule A·2 • Investments - schedule attached III Schedule 0 • Income - Gifts - schedule attached o Schedule B • Raal Properly - schedule attached III Schedula E • Income - Gifts - Travel Paymenfs - schedule attached -or· o None· No reporlable intarasls on any schedule 5. (c)(1) ⁾† (c)(1) I certify under penalty of pe~ury under the laws of the State of Cal~omla that th Date Signed "1- I L -6 I I $'" Signature ⁾† (mmth. dtI;:)M'1 FPPC Form 700 (2014/2015) FPPC Advice Email: [email protected] FPPC To/(-Free Helpline: 866/275-3772 www.!ppc.ca.gov SCHEDULE A-1 CAUFORNIAFORM 700 Investments fA!R pounCAL PRJ;CTICE:5 COMM!S$~N Stocks, Bonds, and Other Interests Name (Ownership Interest is Less Than 10%) Richard Bloom Do not attach brokerage or financial statements. II- NAME OF BUSINESS ENTITY ... NAME OF BUSINESS ENTITY Activislon, Inc, GENERAL DESCRIPTION OF THIS BUSINESS GENERAL DESCRIPTION OF THIS BUSINESS Technology FAIR MARKET VALUE FAIR MARKET VALUE D $2,000 - $10,000 III $10,001 - $100,000 D $2,000 - $10,000 D $10,001 - $100,000 o $100,001 - $1,000,000 DOver $1,000,000 0$100,001 - $1,000,000 DOver $1,000,000 NATURE OF INVESTMENT NATURE OF INVESTMENT III Stock D Other ------;;==:----- D Stock D Other -----:::---,----- (De&a1be) I-I o Partnerehip 0 Income Recefved of $0 - $499 o Partnership o Income Received of $0 - $499 o Income Received of $500 or More (Repolt on Schedule C) o Income Recel\led of $500 or More (Rep:l1t on ScMduJe C) IF APPLICABLE, LIST DATE: IF APPLICABLE, LIST DATE: --'--'...iL --'--'...iL --'--'...iL --'--'...iL ACQUIRED DISPOSED ACQUIRED DISPOSED .... NAME OF BUSINESS ENTITY ... NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS GENERAL DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE FAIR MARKET VALUE D $2,000 - $10,000 D $10,001 - $100,000 0$2,000 - $10,000 D $10,001 - $100,000 o $100,001 - $1,000,000 DOver $1,000,000 0$100,001 - $1,000,000 D Ovar $1,000,000 NATURE OF INVESTMENT NATURE OF INVESTMENT D Stock D Other - ___-;;::== _____ D Stock D Othar -----;;::=:::;----- (Describe) I """"'"I D Partnership a Income R!!ICBlved of $0 - $499 o Partnership 0 Income Received of $0 - $499 o Income Recetved of $500 or More (R&parl on ~8 C) o Income Received of $500 or More (Rep:l1t 011 ~ CJ IF APPLICABLE, UST DATE: IF APPUCABLE, LIST DATE: --'--'...iL --'--'...iL --'--'...iL ACQUIRED DISPOSED DISPOSED ... NAME OF BUSINESS ENTITY ... NAME OF BUSINESS ENTITY GENERAL DESCRIPTION OF THIS BUSINESS GENERAl DESCRIPTION OF THIS BUSINESS FAIR MARKET VALUE FAIR MARKET VALUE o $2,000 - $10,000 o $10,001 - $100,000 o $2,000 - $10,000 0$10,001 - $100,000 o $100,001 - $1.000,000 DOver $1,000,000 o $100,001 - $1,000,000 DOver $1,000,000 NATURE OF INVESTMENT NATURE OF INVESTMENT D Stock D Other -----:::---,-,----- D Stock D Other -----=-c-::-;----- (Oesaibe) 1"""""1 o Partnership 0 Income Received of $0 - $499 o Partnership 0 Income Receilled of $0 - $499 o Income Received of $500 or More {RflPOIf on Schedule CJ o Income Received of $500 or More (Rep:l1t Of! Schedu)e C) IF APPLICABLE, LIST DATE: IF APPLICABLE, UST DATE: --'--'...iL --'--'...iL --'--'...iL --'--'...iL ACQUIRED DISPOSED ACQUIRED DISPOSED Commenm: _____________________________________________ FPPC Form 700 (2014/2015) 5th, A-1 FPPC Advice Email: [email protected] FPPC Toll-Free Helpline: 866/275-3n2 www.fppc.ca.gov SCHEDULE C CALIFORNIA FORM 700 Income, Loans, & Business fAIR POlmeAL PRACTICES COM~.USSlOt,j; Positions Name (Other than Gifts and Travel Payments) Richard Bloom to 1. INCOME RECEIVED ... 1. INCOME RECEIVED NAME OF SOURCE OF INCOME NAME OF SOURCE OF INCOME Cedar-Sinai Medical Center ADDRESS (Business Address Accept8ble) ADDRESS (Business Address Acceptable) 6700 Beverly Blvd, Los Angeles, CA 90046 BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE Health Care YOUR BUSINESS POSITION YOUR BUSINESS POSITION GROSS INCOME RECEIVED GROSS INCOME RECEIVED D $500 - $1,000 D $1,001 - $10,000 D $500 - $1,000 D $1,001 - $10,000 D $10,001 - $100,000 III OVER $100,000 D $10,001 - $1'00,000 D OVER $100,000 CONSIDERATION FOR V\'1-IICH INCOME WAS RECEIVED CONSIDERATION FOR V\1-IICH INCOME WAS RECEIVED o Salary IlJ Spouae's Of registered domestic partner', Income o Salary 0 SPOUStl'S or registered domestic partner's Income (For self-employed use Schedule A-2.) (For self-employed use Schedule A-2) D Partnership (Less than 1 (¥lib ownsn;hlp.