HomeMy WebLinkAboutULTIMATE CUSTOM CAR CAREGift to Agency Report
1. Agency Name
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Division„ epartment, or Region (if apir
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reet Address
30o Ce~tenn~~al ~a~
ea Code/Phone Number E-mail
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]envy Contact (name and title)
2. Donor Name and Address
A Public Document
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Date Stamp
CITY OF TUSTi
GIFT TO AGENCY REPORT
For Official Use Only
2009 MaY - S P 2~ ~ 9
^ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
^ Individual
Lass Name First Name
~I ~ W ~ i ~ s t ~t rP~. ~ ~c~l. Sfi~ ~n
Other ~~t~m ~ I CU~t(]m ~G-Y Cdr
Name
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State
Car wash ~~~ ~etail~hg
If "Other" is marked, describe the entity's business activity (if business) or is nature and interests.
If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift:
COmmu i ~ t° $ ~3~-
Name Amount Name
Amount
3. Payment Information C~
Date and Amount of payment Corner than travel) t ~' 2 ~ S ~ ' " ~ 2'~~
(m nth, d y. year) _r (Round to whole dollars)
Travel Payment Information (Round to whole dollars) Location of Travel
Date(s) of Travel $ansportation 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:
`pn~at i o n o f 2 '~ M i n i ~D~~~ ~ ~. ~~~ f -~ c~efrt~ ~~ C.at~ S~ be c~ ~~~ a S
Taff I~ r.~-eS -~rannr~.a,l C;har• ~ ~r~v~, v~a,[U-~ ~ ~s ~n ~I~ Df Car,
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Identify the~fficials for whom the payment was used:
Last Name First Name Title
Department/Division
Last Name First Name Title Department/Division
4. Verification
1 have determined that it is in the interests of the agency to accept this gift and use if for the official agency business described above.
Signature of Agency Head or Designee
Print Name
Comment: (Use this space or an attachment for any additional information.)
Title (month, day, year)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)