HomeMy WebLinkAboutPATRIOTS FEDERAL CREDIT UNIONGift to Agency Report A Public Document GIFT TO AGENCY REPORT
1. Agency Name -
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Division, Department, or Region (if applicable) For Official Use Only
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S rest Address
rea Code/Phone Number E-m I
'~ ~ ~. . « ~ Amendment (explain in comment section)
nc Contact name and title) Date of Original Filing:
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2. Donor Name and Address
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^ Individual Qther ~~ .Y--'~,~~ ~ ~"1~~{~'t V„~ C,~~~~(,~I~i~i
Last Name ~ Name
/1 t~~1 a ~~ ~ 1 z _~ r~ ./7First Name - T- _ -
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If Other" ~s marked describe the entity s business activity (if business) or its nature and interests,
applicable, identify the name of each source and the amount(s) solicited or received by the donor far this gift:
Name ~ Amount
Name Amount
3. Payment Information
Date and Amount of Payment (ornarrhan rravaq $
(month, day, year} (Round to whole dollars)
Travel Payment Information (Round to whole donors) 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:
Identify the officials for whom the payment was used:
Last Name First Name Title DepartmenUDivision
Last Name First Name
Title DepartmenUDivision
4. verltlcatlon
l have determined that it is in the interests of the agency to accept this gift and use it for fhe official agency business described above.
~ ~ ~:
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ignature of A enc Head or Designee rin Name Title (month, day, year)
COIT11Tlent: (Use this space or an attachmenf for any additional information.)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772)