HomeMy WebLinkAboutSANTA ANA TUSTIN PHYSICAL THERAPYGift to Agency Report A Public Document GIFT TO AGENCY REPORT
. Hgency rvame
City of Tustin
Division, Department, or R
Parks and Recreation
Street Address
300 Centennial Way
Area Code/Phone Number
(714) 573-3326
Agency Contact (name and
Date Stamp
(if applicable)
SKing@tustinca.org
Sarah King, Recreation Coordinator
2. Donor Name and Address
^ Individual ^x Other Santa Ana Tustin Physical Therapy
Last Name First Name Name
1910 Old Tustin Ave. Santa Ana CA 92705
Addross 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 (ornerthan rravet) 8123/10 $
(month, day, year)
Travel Payment Information {Round ro Whore dottars) 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:
Sponsorship for Tustin Tiller Days -Gold Sponsorship level
Identify the officials for whom the payment was used:
Last Name First Name
Last Name First Name
Amendment (explain in comment section)
Date of Original Filing:
2,500.00
(Round to whole dollars)
Title
Title
For Official Use Only
DepartmenUDivision
DeparEmenUDivis(on
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.
7
%~'~ _ Sarah King Recreation Coordinator 8/27/10
S(gnature of Agenc Head or e gnee Print Name Title (month, day, year)
COnlfl'lent: (Use this space or an attachment for any additional information.)
(month, day year)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/2753772)