RECEIVED

CALIFORNIA FORM 700 STATEMENT OF ECONOMIC INTERESTS

!;i~"C~r. -, .
Date Received
Officwl Use Only

FAIR POLITICeL PRACTICES COMMISSION ~ MAR -1 2011

A UBLIC DOCUMENT COVER pAG~)~')I:}''':>' - ~ -, '_.I_ .'_'
BY: 1'&
Please type or print in ink.
ZD II MAR - I PCj 5: ': I;
NAME OF FILER (LAST) (FIRST) (MIDDLE)

Miller Jeff M
1. Office, Agency, or Court
Agency Name
California State Assembly
Division, Board, Department, District, if applicable Your Position
District 71 Assemblymember
.. If filing for multiple positions, list below or on an attachment.

Agency: Position:

2. Jurisdiction of Office (Check at 'east one box)

~S(ate o Judge (Statewide Jurisdiction)
o Mulli-Counly _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ o Counly 01 _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
o Cily 01 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ o Olher
3. Type of Statement (Check at least one box)
~ Annual: The period covered is January 1, 2010, Ihrough December 31, o Leaving Office: Dale Left ----1----1_ _
2010. -or· (Check one)
The period covered is ----1----1_ _, Ihrough December 31, o The period covered is January 1, 2010, through the date 01
2010. leaving office.

o Assuming Office: Date ----1----1_ _ o The period covered is ----1----1_ _, through the date
of leaving office.

o Candidate: Election Year _ _ _ _ _ __ Office sought, il different than Part 1: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

4. Schedule Summary
Check applicable schedules or flNone." ... Total number of pages including this cover page: _Lf..L.._
o Schedule A·1 - Inveslmenls - schedule attached D Schedule C - Income, Loans, & Business Positions - schedule attached
~ Schedule A·2 • Inveslmenls - schedule attached ~ Schedule D • Income - Giffs - schedule attached
o Schedule B • Real Propelly - sChedule attached o Schedule E • Income - Giffs - Travel Paymenls - schedule attached
-or-
O None· No repollable inleresls 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 01 the State 01 California that

Date Signed _ _ _ ~~::::.::7.:,'=. .:::'2.=;_O-l'\,t.--

(mon/h, day. year)

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)

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

Jeff Miller Insurance Agency

Name Name
218 N. Lincoln Ave #102, CA 92882
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

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 510,001 - $100,000 ----1----1.JiL ----1----1.JiL D $10,001 - $100,000 ----1----1JJL ----1----1JJL
~ $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

[8]
Sale Proprietorship o Partnership D Other
D Sale Proprietorship o Partnership D Other
YOUR BUSINESS POSITION Owner 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 IQ THE ENTITYITRUST) SHARE OF THE GROSS INCOME JQ THE ENTlTYITRUSTj

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

D $500 - $1,000 DOVER $100,000 05500 - $1,000 DOVER $100,000
D 51,001 - $10,000 0$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 (Attach II SCp;lroto sheet II neccs~ryl INCOME OF $10.000 OR MORE (Attach 0 SCp;ll'iJto sheet II nec;e$~ry.1

... 4. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD §Y THE ... 4. INVESTMENTS AND INTERESTS IN REAL PROPERTY HELD §Y 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 0$10,001 - $100,000
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 OwnershiplDeed of Trust D Stock D Partnership D Property Ownership/Deed of Trust D Stock o Partnership

D Leasehold D O'h.r _ _ _ _ _ _ _ _ __ D Leasehold

D Oth.r _ _ _ _ _ _ _ _ __
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: _______________________ FPPC Form 700 (201012011) Sch. A-2

FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
 CALIFORNIA FORM
FAIR POLITICAL PRACTICES COMMISSION
700
SCHEDULE D
Name
Income - Gifts

to- NAME OF SOURCE ,.. NAME OF SOURCE

Sothern California Edison California Tribal Business Alliance

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

2245 Walnut Grove Ave. Rosemead CA 91771 1530 J Street, Suite 400 Sacramento CA 95814
BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE

DATE (mmlddlyy) VALUE DESCRIPTION OF GIFT(S) DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S)

~E.J~ $L----'..73::;..::.65=_ Food & Beverages Food & Beverages

---.l---.l_ $_ _ _ _

---.l---.l_ $ _ _ __

... NAME OF SOURCE ... NAME OF SOURCE

California New Car Dealers Association John Perez for Assembly

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

1415 L Street, Suite 700 Sacramento CA 95814 777 South Figueroa Street, Ste 4050 Los Angeles CA
BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE

DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S) DATE (mmldd/yy) VALUE DESCRIPTION OF G1FT{S)

Food & Beverages E...J~~ $_ _1:...:1.::..0 Portfolio

---.l---.l_ $ _ _ __

$ $

... NAME OF SOURCE ... NAME OF SOURCE

Rio Tinto Minerals, U.S. Borax Inc. Visa, Inc.

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

P.O. Box 6609 Englewood CO 80155 1300 Connecticut Ave, Ste 900 Wash. DC 20036
BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE

DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S) DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S)

~~~ $ 129.17 Food & Beverages _~_L_~_.J~ s 166.90 Food & Beverages

---.l---.l_ $._ _ __

---.l---.l_ $; _ _ __ ---.l---.l_ $,_ _ __

Comments: ............................................................................................................................................................................................................................................................

FPPC Form 700 (2010/2011) Sch. D

FPPC Toll-Free Helpline: 866/275-3772 www.fppc.ca.gov
 CALIFORNIA FORM 700
FAIR POLITICAL PRACTICES COMMISSION
SCHEDULE D
Name
Income - Gifts

~ NAME OF SOURCE ,.. NAME OF SOURCE

John Wayne Airport Orange County Business Council

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

3160 Airway Ave. Costa Mesa CA 92626 2 Park Plaza, Suite 100 Irvine CA 92614
BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE

DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S) DATE (mm/dd/yy) VALUE DESCRIPTION OF G1FT(S)

~..EJ~ $ 200.00 Parking .

2.L_~ ..J~ $ 250.00 Food & Beverages

-----1-----1_ $, _ _ __ -----1-----1_ $, _ _ __

-----1-----1_ $._ _ __ -----1-----1_ $_ _ __

,.. NAME OF SOURCE ... NAME OF SOURCE

State Farm San Francisco 4gers

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

1201 K Street, Ste 920 Sacramento CA 95814 4949 Centenial Blvd Santa Clara CA 95054
BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE

DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S) DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S)

2.J..EJ~ $ 290.00 Sports Event ~ 27 I~ $ 303.00 Sports Event

-----1-----1_ $,_ _ __ -----1-----1_ $, _ __

$ $

.... NAME OF SOURCE ,.. NAME OF SOURCE

Sothern California Edison

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

2244 Walnut Grove Ave. Rosemean CA 91770

BUSINESS ACTIVITY, IF ANY, OF SOURCE BUSINESS ACTIVITY, IF ANY, OF SOURCE

DATE (mm/ddfyy) VALUE DESCRIPTION OF GIFT{S) DATE (mm/dd/yy) VALUE DESCRIPTION OF GIFT(S)

.2J~~ $ 346.35 Sports Event ~-----1_ $ _ _ __

-----1-----1_ $ _ _ __ -----1-----1_ $ _ _ __

-----1-----1_ $,_ _ __ -----1-----1_ $ _ _ __

Comments: ____________________________________________________________________________________

FPPC Form 700 (2010/2011) Sch. D

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