HomeMy WebLinkAboutSTORAMERICA MANAGEMENTGift to Agency Report
1. Agency Name
sion, Department, or Region {rf applicable)
Address
A Public Document
GIFT TO AGENCY REPORT
For dfficial Use Only
'a Code/Phone Number E-mail
Amendment (explain in comment section)
ency Contact (Warne and title) Date of Original Filing:
(month, day, year)
2. Donor Name and Address
^ Individual [.Other '
Last Name First Nama _ ~ flame
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 amounts} solicited or received by the donor for this gift:
,,,f ,.
Name ~ ~ ~ Amount ~ Name ~ Amount
3. Payment Information
Date and Amount of Payment (otnerrnan rravei)
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dolars) ~ocatian of Travel
Date{s} of Travel Transportation Expenses ~ Cadging 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 wham the payment was used:
Last Name First Name Title
DepartmenUDivision
Last Name First Name Title Department/Division
4. Verification
i have determined that if is in'interests of the agency to accept this gift and use if for the official agency business described above.
a ~ ~ ~ ~ _ ~.
Signature of Agency Head ar Designee Print Name
~Onlment: (Use this space or an attachment far any additional information.}
(month, day, year)
Date Star~~p
FPPC Form 801 (June/08)
FPPC Toli-Free Heipline: 866tASK-FPPC (866/275-3772)