HomeMy WebLinkAboutLAILA NAYAB, DC CHIROPRACTORGift to Agency Report
1. Agency Name
City of Tustin -Parks and Recreation
on,
300 Centennial Way
itreet Address
Tustin, CA 92780
or Region (if applicable)
A Public Document
-rea ~oaetrnone rvumper I t-man
(714) 573-3326
-gency Contact (name and title)
Carrie Woodward -Recreation Coordinator
2. Donor Name and Address
^ Individual
Address
First Name
Zip Code
If "Other" is marked, describe the entity's business a6tivity (if business) or its natur 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 p
Date and Amount of Payment (other than travel) ~~ ~~ $ 1 ~` ~~
( ont day, year) (Round to whole do!!ars)
Travel Payment Information (Round to whole donors) location of Travel
Dates} 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:
Identify the officials for whom the payment was used:
Last Name First Name
Last Name First Name
Date Stamp
GIFT TO AGENCY REPORT
i~ ~ `~ i '~ ~ For Official Use Only
~FICi/-"CU5TIN CITY rLERf<
^ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
~I'll..A' l ~~'~-JKP~ IBC - ~.~I' ~ Vim'/ i
Name
Trtla
Title
Department/Division
Department/Division
--
4. Verification ~1
I have determined that it is in t e /ipterests of the agency to accept this gift and use it for the official agency business described above.
~ ~ ~ ~r ~ ~ ~ ~~t
~ ~ i ~~, ~ ' . ~ ~ ~~
Signatur ' f Agency Head or esignee Print ame iUe
(mo th, day, year)
COITtnlent: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June108)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)