HomeMy WebLinkAboutDROUIN REALTY INC (2)Gift to Agency
1. Agency Name
City of Tustin
or
POlice Department
300 Centennial Way
714 573-3396
rortiz@tustinca.org
Agency Contact (name and title)
Ruby Ortiz :Police Services Officer
2. Donor Name and Address
For Official Use Only
Amendment (explain in comment secL'on)
Date of Original Flling:
(month, day, year)
^ Individual ®Other Drouin Realty Inc.
Last Name First Name Name
14081 Yorba Street Tustin CA 92780
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:
Drouin Realty Inc. $ 100.00 $
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (other than travel) $
(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:
Funds were used for the Walk to School Program.
Identify the officials for whom the payment was used:
Last Name First Name Title DepartmenUDivision
Last Name First Name Title Department/Division
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.
~ / ;
~ ~ ~~~ ~~ ~ ~ -' .~~ Scott M. Jordan Chief of POlice 1-5-11
Signature of Agenc~ ead or Designee Print Name Title (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
A Public Document
Date Stamp
GIFT TO AGENCY REPORT
~~~ fir- ! b~;~~4~~
2~1! JRN 18 A ~~ 5 5
FPPC Form 801 (June/08)
FPPC Toll-Free Helpllne: 868IASK-FPPC (866/275-3772)