HomeMy WebLinkAboutROUGHFIT, INC (2)Gift to Agency
1. Agency Name
City of Tustin
rt
A Public Document
Division, Department, or Region (if applicable}
Parks and Recreation
Street Address
300 Centennial Way
\rea Code/Phone Nun
(714) 573-3326
(name and
SKing@tustinca.org
Sarah King, Recreation Coordinator
2. Donor Name and Address
Date Stamp
GIFT TO AGENCY REPORT
For Official Use Only
Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
^ Individual ^x Other Rough-Fit, INC
Last Name First Name Name
12401 Browning Ave. Santa Ana CA 92705
Address City State Zip Code
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:
$ $
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment lornerrnan craveO
6/11 /2010
(month, day, year)
~ 75.00
(Round to whole dollars)
Travel Payment Information (Round to Whole aouarsi 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:
Sponsorship for 2010 Movies in the Park
Identify the officials for whom the payment was used:
Last Name First Name Title DepartmenUDivision
Last Name First Name Title DepartmenUDivision
4. Verification
I 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.
~~ /~ Sarah King Recreation Coordinator 8127/10
Signature of Agenc Head siynee Print Name Title (month, day, year)
Comment: (Use this space or an attachment for any additional information.}
FPPC Form 801 (June/O8)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)