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-ALIFORNIA FORM 700IR POLITICAL tRACrlCr.:S COMMISSION
(MIDDLE)
S T AT E M E N T O F E C O N O M I C IN T E R ES T S
C O V ER P A GE
ase type or print in ink. A Public DOCUlnent
ME (LAST} (FIRST)
e La Pena William Charles ( 323 ) 728 5500
ILING ADDRESS STREET
ay use business address)
CITY STAT E Z iP CODE OPTIONAL FAX E-M.L,IL ADDRESS
Montebello446 W. Whittier Blvd.
. Office, Agency, or Court
Name of Office, Agency, or Court
University of California
Division, Board, District if applicable:
Board of Regents
Your Position:
Regent
~ If filing for multiple positions, list additional agency(ies)/
position(s): (Attach a separate sheet if necessary)
Agency
Position: -,--- _
2. Jurisdiction of Office (Check at least one box)
!gj State
o County of ----------------o City of _
o Multi-County ----------------
LJ Other ------------------
3. Type of Statement (Check at least one box)
o Assuming Office/Initial Date -----.J-----.J__
I X ! Annual: The period covered is January' 1. 2008.through December 31, 2008.
-or-O The period covered is -----.J-----.J__ , through
December 31. 2008.
LJ Leaving Office Date Left: -----.J-----.J--(Check one)
o The period covered is January 1. 2008. through the
date of leaving office.
-or-
o The f::-eriodcovered is f-----.J , through
CA 90640
4. Schedule Summary
... Total number of pages 10including this cover page: _
~ Check applicable schedules or "No reportable
interests. "
I have disclosed interests on one or more of the
attached schedules
Schedule A-1 0Yes - schedule attached
Investments (Less than 10% Ownership)
Schedule A-2 I R l Yes - schedule attached
Investments (10%or greater Ownersh(o)
Schedule B I R l Yes - schedule attached
Real Property
Schedule C I8 l Yes - schedule attachedIncome, Loans, & Business Positions (Income Other than Giftsand Travel Payments)
Schedule D 0Yes - schedule attached
Income - Gifts
Schedule E nYes - schedule attachedIncome - Gifts - Travel Payments
-or-
o No reportable interests on any schedule
5.Verification
I have used, all reasonable diligence in preparing this
statement I have reviewed this statement and to the best
OhflY knowledge the information contained herein and in anyattached schedules is true and complete.
I certify under penalty of perjury under the laws of the State
of California that the foregoing is true and correct.
Date Signed 3/26f2009/7 {month. day. ye8r}~
/ /.~.~/ // --//>'::"/Signature > / / - ~ CL-"- 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
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I MED-lASER SURGICAL CENTER
SCHEDULE A-2
Investments, Income, and Assets
of Business Entities/Trusts(Ownership Interest is 10% or Greater)
De La Peiia Eye Clinic
Name
2446 W. Whittier Blvd., Montebello, CA 90640
,--- .. " ... '..;,,; .. :c;';:; .,~.
~CAUFORl\I'A F O R M 7 f f J FAIR POUTICAL PRA CT ICEStQr"'llfsiIO~ ~:!. : . . . : : . : ~ _ - : < : . " ' : . : : : ; ) ~ ; ~ \ . , _ , ' . . ~ _ - . . ;_ ::L , -;~ : '";r :--(, ;, . . ; i '_ : . : ' : ~ ' , , : :
I Name
I Wil liam C. De La Per i l
Address
Check one
o Trust, go to 2
Name
2445 W. Whittier Blvd., #100; Montebello, CA 90640Address
Check one
o Trust, go to 2eg Business Entity, complete the box, then go to 2 ! & l Business Entity, complete rhe box, then gGENERAL DESCRIPTION OF BUSINESS ACTIVITY
Ophthalmology Practice',GENERAL .OESCRIPTION OF BUSINESS ACTIVrr;'
IF APPLICABLE. LIST DATE: IF APPLICABLE. LIST DATEFAIR MARKET VALUE
o$2,000 ' $10,0000$10.001 - $100.000
oS100.001 - 51.000.000'~Over 51.000.000
__ 1.._-.108
DISPOSED
FAIR MARKET VALUE
oS2.000, $10.0000$10,001 - $100.000
o$100.001 ' $1.000.000[81 Over S1.000.000
NATURE OF INVESTMENT
~ Sole Proprietorship 0Partnership 0 _O IP
. Qlh~rYOUR BUSINESS POSITION wne!'; resident/PhysiCIan
---"---1~;'COUIRED
NATURE OF INVESTMENT
!8 l Sole Proprie!Orsllip 0Partnership 0 _YOUR BUSINESS pOSrnON OwnerlPresidentlSurg':>n
o SO - $49905500, S1.000
o $1.001 - $10.000o$10.001 - $100,0001 8 l OVER S100.000
3 : tiS T THE t.J J \t . .'F {)F ["fl.CHRrpORTf~B! ~: 5ri\iGt [ SOURCr OF
INCO~E OF $10.0.~O OR MORE ,'''",,,, ,+~,...'" .~,."'!" ",,0...'',;
o SO, $4990$500, S1.000
o $1,001 ' $10.000oS10,001 ' $100,000I & l OVER $100.000
see attached
~:: liST THE NAME OF EACH HEPORlABLE sir.GtE SOURCE or
INCOM.EOF S1,M!lO.9R..MOi'!E (' '!.!
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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
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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
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SCHEDULE A"2
Investments, Income, and Assets
of Business EntitieslTrusts(Ownership Interest is 10% or Greater)
.. 1, BUSINESS ErmTY OR TRUST
De La Pena Family Trust dated 11~6/01Name
2446 W. Whittier Blvd., Montebello, CA 90640Address
Check one
l& ! Trust, go to 2 o B'!siness Entity, complete the box, then go to 2
GENERAL DESCRIPTION OF BUSINESS ACTIVITY
FAIR MARKET VALUE
'0 $2,000 - $10.000
0$10,001 - $100,000
0$100,001 - $1,000,000
DOver $1,000,000
NATURE OF INVESTMENT
o Sole Proprietorship 0Partnership 0 _Other
IF APPLICABLE LIST DATE:
---...J---.I 08ACQUIRED
---1---108DISPOSED
iYOUR BUSINESS POSITION _
0$0 - $499
o $500 - $1,0000$1,001 - $10,000
0$10,001 - $100,000
!8 l OVER $100,000
~ ~ LIST rHErJht-./~[ OF [f..(~H~fPORTAP.LE Slf';G1.f 'SOURCE Of
INCOME OF S10,OOO OR MORE '"',,," " ":,'-". ,,,,,,,,,. C"""",,,~,
CALIFORNIA FORM '1O O FAIR ?QUT1CAL PRf.CTfCES COMMISSIOtt,~';
~,,'d'>!:'
I Name
! William C. De La Pena
De La Pena Family Trust dated 11/26/01Name
2446 W. Whittier Blvd., Montebello, CA 90640Address
Check one
~ T ru st , go to 2 0Business Entity, complete the box, then go to 2
GENERAL DESCRIPTION OF SUSINESS ACTIVITY
IF APPLICABLE UST DATE'FAIR MARK.."'T VALUE
051,000 - $10,000
o$10,001 . $100,0000$100,001. - $1,000,000
DOver S1,000.000
---.J---.108
ACQUIRED---.J---.J
08
DISPOSED
0$0 - $499
0$500 - $1,000
o $1,001 - $10,000
Other
0$10,001 - $100,000
! & l OVER $'100,000
Med-Laser Surgical Center. Goldex Jewelry
,., ? I,:sr TilF ~;M.1For- U.CH R!';JOfH/\BU: SI:'JGIf SOURCE orINCOME OF S1G,OOO OR MORE f"'."h. '.
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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 Y z W. WHITTIER BLVD.
MONTEBELLO, CA 90640
TENANT: Fernando Vera $1,000 - $10,000
FAIR MARKET VALUE $100,001 - 1,000,000
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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 BLYD.
MONTEBELLO, CA 90640
TENANT: NIA
FAIR MARKET VALUE $100,001 - 1,000,000
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SCHEDULE A-2
Investments, Income, and Assets
of Business Entities/Trusts(Ownership Interest is 10% or Greater)
1. BUSINESS ENTITY OR TRUST
De La Pena Family Trust dated 11/26/01
ame2446 W. Whittier Blvd., Montebello, CA 90640ddress
Check one
~ Trust. go [0 2 o Business Entity. complete the box. then go to 2
ENER,i;.L DESCRiPTiON OF BUSiNESS .A.GTIViTY
AIR M,"-.RKET \1.ll,LUE
S2.000 - 510.000
$10.001 - $100.000
5100.001 - $1.000.000
Over S1.000.000
IF A.PPLICABLE. LIST DATE
---.J.---..l 08ACQUIRED
_ _ 1_ _ 108
D!SPOSED
ATURE OF tNvESTrvlENT
~0Soie Proprietorship 0Partnership 0 -,- _ Other
OUR BUSINESS POSITION _
2. IDENTIFY THE GROSS INCOME RECEIVED (INCLUDE VOUR PRO RATA
SHARE OF THE GROSS INCOME IQTHE ENTrrYfTRUSn
! so - 8499
nS500 - SI :000
o 51.001 - $10.000
! X l $10,001 - S100.000
DOVER $100.000
. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE OF
INCOME OF S10,GOO OR MORE i.;~."" , .."....' it"*..,,I ," . , ."" .~ , . i
r. Guindi
. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD BY THE
BUSINESS ENTITV OR TRUST
heck one box:
o iNVESTMENT f 8 J REAL PROPERTY760 Avenida del Mundo
me of 'Business Entity ill
eet )I.,ddress or p.ssessor's Parcel Number of Real Property
oronado, CA 92118scription of Business Activity Q[
y or Other Precise Location of Rea! Property
IR M."'.RKET VALUE
S2.000 - $10.000
$10,001 - $100.000
n5100.001 - 51.000.000
Over $1,000.000
IF ,A'pPUC,A.BLE. UST DATE:
---.J---.J 08 ---.J__ p8;CQUIRED DISPOSED
TURE OF iNTEREST
Property Ownership/Deed of Trust o Stock o Partnership
nLeasehold C J Other ~ __
Yrs. remaining
Check box if additional schedules reporting investments or real Dropenyare attached
CALIFORNIA FORM 700FAIR POllnCA!. PRACTICES COMMiSSION
Name
William C. De La Pefia
1. BUSINESS ENTITY OR TRUST
Name
Address
Check one
o Trust. g o t o 2 o Business Entity, complete the box, then go to
----------_. ._._------FAiR MJ..RVET 'VAlUE
o S 2.D O I ) . S 10.Q (H : "D$10.001 . SH)O GDOo $iC!0r.JCf $10DL!0CCo O'.l'~r $~.DOG.DOGNATURE. C,F it'J;JESTMENT
n Sote Prop!tt-!t~)fShip n P8;me{~.hlc
,08
.:!:o,(.Cr)JPED
[] ,,-,-
2. IDENTIFY THE GROSS INCOME RECEIVED (lNCWOE YOUR PRO RATA
SHARE OF THE GROSS INCOME 12THE ENTITYITRUSn
050 - $499
05500 - 51.000
051,001 - $10.000
0$10.001 - $100.000
DOVER 5100.000
.. 3. LIST THE NAME OF EACH REPORTABLE SINGLE SOURCE orINCOME OF S10.000 OR MORE I,>tt.",n " '4'P...~, h... : ',,""' ... -..rf'
Check one box:
o INVESTMENT
~ 4, INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD .Y. THE
BUSINESS ENTITY OR TRUST
o REAL PROPERTY
Name of Business Entity ill
Street Address or Assessor's Parcel Number of Real Property
Description of Business A.ctivity ill
City or~Other Precise Location of Reai Property
FAIR MARf
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SCHEDULE C
Income, Loans, & Business
Positions(Other than Gifts and Travel Payments)
CALIFORNIA FORM 700FAIP. POLmCAl PRACTICES COMMISSION
Name
William C. De La Pena
NAME OF SOURCE OF INCOME
NAME OF SOURCE OF INCOME
De La Pena Eye Clinic
ADDRESS
2446 W. Whittier Blvd., Montebello, CA 90640
BUSINESS ACTIVITY. IF ANY OF SOURCE
Ophthalmology Practice
YOUR BUSINESS POSITION
Owner/President/Physician
GROSS INCOME RECEIVED
o 5500 - 51.000 0 $1.001 - 510.0000510.001 - S100.QOO ~ OVER S100.000
CONSIDERA.TION FOR WHICH INCOME WAS RECEIVED
~ S al ary 0Spouse's Of registered domestic partner's income
o Loan repaymento Sale of
(Property, caT.-boat, etc.)
i j Commission or tJ Rental lncome. list each source of 510,000 or more
UOther{Describe)
. '
Med-Laser Surgical Center
ADDRESS
2445 W. Whittier Blvd., #100; Montebello, CA 90640
BUSINESS ACTIVITY. IF ANY. OF SOURCE
Ambulatory surgical center
YOUR BUSINESS POSITION
Owner/President/Surgeon
GROSS INCOME RECEIVED
o S500 - $1.000 051.001 - S10.0000$10.001 - S100.000 ~ OVER $100.000
CONSIDERATION FOR WHICH INCOME WAS RECEIVED
o Salary n Spouse's or registered domestic partner's incomeo Loan repaymento SaJe of
(Property. car, boac. etc.)
o Commission or 0Rental Income. fist each source of $70.000 or more
Qg Other Owner's draw/Director's fee(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 partof 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 receivednot in a lender's regular course of business must be disclosed as follows:
NAME OF LENDER'
Self to De La Pena Eye Clinic
.A.DDRESS
2446 W. Whittier Blvd., Montebello, CA 90640
BUSINESS ACTIVITY IF ANY OF LENDER
Administration/Physician
HIGHEST BALA.NCE DURING REPORTiNG PERIOD
[J$500 - $1.000
D $1.001 - S10.000
U$10.001 - $100.000
[gj OVER S100.000
Comments:
INTEREST RATE TERM (MonthsiYears)
_____ % [gj None
SECURITY FOR LOA.N
Q g None 0Personal residence
[] R ear Property Str eet addnE- '. ' ;5
City
oGuarantor --- _
o Other {Describe}
FPPC Form 700 (2008/2009) Sch. C
FPPC Toll-Free Helpline: 866/ASK-FPPC www.fppc.ca.gov
http://www.fppc.ca.gov/http://www.fppc.ca.gov/ -
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SCHEDULE C
Income, Loans, & Business
Positions(Other than Gifts and Travel Payments)
CALIFORNIA FORM 7FAIR POLl!lCAl PRACTICES cm'::MI
- -
William C. De La Pen
NAME OF SOURCE OF INCOME
De La Pena Eye Clinic.ADDRESS
2446 W. Whittier Blvd., Montebello, CA 90640BUSINESS A.CTIVITY. IF ANY. OF SOURCE
Ophthalmology Practice
YOUR BUSINESS POSITION
Book keeping/Managerial
GROSS INCOME RECEIVED
o 5500 - $1.000 0$1001 _ S10.000I 8 J $10.001 - $100.000 0OVER S100.000
CONS!DERATION FOR VVHICH INCOME WAS RECEIVED
oSalary c g ) Spouse's or registered domestic partner's income
o Loan repaymento Sale of -::;:=-:-_--:- _
(Property. car,. boal. etc)
[] Commission or o Rental income. list each source of $10,000 or more
nOther (Describej
NAME OF SOURCE OF INCOME
YMCA
ADDRESS
12510 E. Hadley, Whittier, CA 90601BUSINESS ACTIVITY, IF ANY. OF SOURCE
Community resourceYOUR BUSINESS POSITiON
Aerobic/Group Exercise Instructor
GROSS INCOME RECEIVED
0 $5 00 - $1 .0 .0 0
o $10,001 - S100,000f Z 1 $1,001 - 510,000
DOVER S100.000
CONSIDERAT!ON FOR WHICH INCOME W,A,S RECEIVED
o Salary 0Spouse's or registered domestic partner's incomeo Loen repaymento Sale of
(Property' car, boal, etc.)
o Commission Or o Rental Income. iist each Source of 510,000 or mo
o Other (Describe)
. . . ' .W lOjM i#N #,',Jji, liiM W illM i,j iM @ iU ii;JigI;'M ### ;1[-1'
* You are not required to report loans from commercial lending institutions, or any indebtedness created as paof 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 receivednot in a lender's regular course of business must be disclosed as follows:
N,A.ME OF LENDER"
Self to Med-Laser Surgical CenterADDRESS
2445 W. Whittier BlVd., #100; Montebello, CA 90640BUSINESS ACTiVITY. IF ANY. OF LENDER
Administration/Surgeon
HIGHEST BALANCE DURING REPORTING PERIOD
o 5500 - 51.000U S1.0Q1 - $10.000
Ll 510.001 - $100.000
I& J OVER S100.000
Comments:
!NTEREST RATE TERM (MonthslYears)
----% I& J None
SECURITY FOR LOAN
I & J None 0Personal residence
E J' Peal Property Sireet address
City
o Guarentcf ___
oOther (Describej
FPPC Form 700 (2008/2009) Sch C