HomeMy WebLinkAboutGSC GATEWAY, LPa~~
Department, or Region
Gift to Agency Report A Public Document
1. Agency Name ~ n ~ ~ ~
cy Contact (name and title) ~ "
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2. Donor Name and Address
^ Individual
_ ~~ ~ ., ,. ,.Last Name _ \ _.
Address
First Name
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Other
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GIFT TO AGENCY REPORT
For Official Use Only
Amendment (explain in commentsection)
r~f Original Filing:
(month, day, year)
Name
tee, C~~
State Zip Code
If "Other" is marked, describe the entity's business activity (if business) or its nature and interests.
If applic(a~b~le~i-d{entify the-name of ea`ch~source and the amount(s) solicited or received by the donor for this gift:
lJ 1 ,~ $ ~ l.~ ~ ~ $
Name J Amount Name Amount
3. Payment Information
Date and Amount of Payment (ornerrnan travel) $
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dollars) 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 Department/Division
Last Name First Name Title Department/Division
4. Verification
I have determined that it is in the terests of the agency to accept this gift and use it for the official agency business described above.
Signature of Agency Head or Designee Print Name Title (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June/08)
FPPC ToII-Free Helpline: 866/ASK-FPPC (866/275-3772)