HomeMy WebLinkAboutTUSTIN RANCH GOLF CLUBGift to Agency Report A Public Document
1. AgencX~-{Name(~}~ (~ C
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Divisi~o(n, DeMrtment, or Rpeg[ion~(~ifa/pplipcable)
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Area
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Code/Phone Number E-mail
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cy Contact (name and title)
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Z. Donor Name and Address
^ Individual
Last Name
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Date Stamp
Y 0~ TUSTIN
AY -S P 2~ 59
GIFT TO AGENCY REPORT
For Official Use Only
Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
Other J "`~~~~ ^yl- -CI'' 1.~~1~~1""~
First Na e ~ Name
r.~r State Zip Code
~-~ off' Course ~ ReSficu~,~a-ant-
If "Other" is marked, describe the entity's business activity (if business) or its nature and interests.
If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift:
Cyr 1 I~INI t'~-1 ~~~~ ~I 11 ~~$~~_ $ Amount
ame Amount Name
3. Payment Information
Date and Amount of payment (ornerrnan travel) ~ S ~~ I S ~~
( onth, day, year) -~ (Round to whole dollars)
Travel Payment Information (Round to whore ao/~ars) 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:
donation o-~ Sunda gr,~n~h r 2 C~~7-~i~) and 2 ids of Caal~ w~
Car+ ~~ ~ ~2~b) I~ u,S as raf ~f I~ pY~~eS -For sari ~riv~
Identify the officials for whom the payment was used:
Last Name First Name
Title
DepartmenUDivision
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.
Signature of Agency Head or Designee Print Name Ttle (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772)