HomeMy WebLinkAboutROUGH-FIT, INC (2)Gift to Agency Report
1. Agency Name
us~ih Tillear DoW~ Camm~
Division, Department, or egion (if apF
Street Address
~j CQiY1~Y1 I Del W ~ ~
Area Code/Phone Number -mail
~)y- ~ - 33210
Agency Contact (name and title)
C~ns~~c Cle~,le,1~0. , ~~re
2. Donor Name and Address
GIFT TO AGENCY REPORT
For Official Use Only
Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
^ Individual ..®'Other ~~)a~- - `h ~" ~~~
Last Name First Name Name
la-yl~a- 3`Nu~~n~usn ~ue..Snv~~-I~. C~~k ~a~GS
Address City State Zip Code
h~e~SS
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:
'iu5~v~ 1 ~1\ex ~S $ ~~p,c~ $
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (ornerrnan travel) ~.,. C ~= $ 1 DO • ~"
( onth, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole donors) 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:
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.
~~i~~~-~ elleurl~~- C~nshne Clecrela,~ _~~rr~~~~~3yr ~ ~ ° °I
Signature of Agency Head or Designee Print Name Tite ( onth, day, year)
Comment: (Use this space or an attachment for any additional information.)
A Public Document
CI
Date Stamp
OF TtlSTIN
-2 P3~11
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)