HomeMy WebLinkAboutSEOUL GARDEN BBQ BUFFETGift to Agency Report
1. Agency Name
Tu~i.-' n .~~~Imar
Division Department, or Region (if applicable)
300 Gen .2nn'~ au
Street Address ^-T
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Area Code/Ph ne Number Enp-mail
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Agency Contact (name and title)
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A Public Document
2. Donor Name and Addrress
^ Individual C hD L ~
Last Name First Name
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Address Cdy
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It "Other' is marked, describe the entity's business activity ('rf business) or its natu
TO AGENCY REPORT
Q~a~e
zo~a ocT - $
'~: F~ Qtfictal Use Only
Amendment (explain in comment section)
Date of Original Flting:
(month, day, yeah
(V10ther l.~C~ul ~ r~~ a 88Q Bu-~-~e~
Zip Code
If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift:
Name $ Amount O Name $ Amount
3. Payment Information In~1
Date and Amount of Payment (other man navel) ~ $ rt5~(J ' 00
(month, day, yeah (Round to whole dollars)
Travei Payment Information (Round to whole dolars) Location of Travel
Date(s) of Travel Transportation Expenses $ Lodging Expenses $ Meal Expenses $ Other Expenses $ Total Expenses
Provide a specific description of the nature and use of the payment for official agency business:
flap ch~clC dona~fion towards C~fy's Neal-Fh Benefifs ~r ~~g•
Identify the officials for whom the payment was used:
Last Name First Name Title Department/Division
Last Name First Name Title DepartmenUDivision
4. Verification
1 have determined that it is in the interests of the agency to accept this gift and use it for the official agency business described above.
~~-l ~"~(~ ~ Kn'sfi' ~Qcchia Di n~cf~r. Numan Q~sour ' `~~3 ~~
Signature of Agency Head or Designee Pnnt Name Title (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June108)
FPPC Toll-Free Helpllne: 866/ASK-FPPC (8861275-3772)
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