HomeMy WebLinkAboutSTATE FARM MUTUAL AUTOMOBILE INSURANCElift t® Agency Report 91 PUI~fIC ®dCUCCleCtt GIFT TO AGENCY REPORT
agency Name
Gity of Tustin -Parks and Recreation
or Region (ifapplicabfe}
300 Centennial Way Tustin, CA 92780
>treet Address
(714) 573-3326
area Code/Phone N
Sarah King 'sking@tustinca.org
agency Contact (name and tine)
Recreation Coordinator
2. Donor Name and Address
Date Stamp • ~ ~~
• ~
For Officio( Use Only
^ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
^ Individual ~ Other State Farm Mutual Automobile Insurance
Last Name First Name Name
3 State Farm Plaza Bloomington IL 61791
Address City State Zip Code
Sponsorship for Summer Concerts in the Park
If `Others is marked, describe the entity's business activity Qf business) or its nature and interests.
If applicable, identify the name of each source and the amounts} solicited ar received by the donor for this gift:
Name ~ Amount Name ~ Amount
3. Payment Information
Date and Amount of Payment (otnertnan travel) 05/06/2011 ~ 1750.00
{month, day, year) (Round to uvhote dollars)
Travel Payment Information iRouna tQ whore dorrars) t_ocation of Travel
$ $ ~ $ $
Dates} 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 wham the payment was used:
Last Name First Name Title
Last Name First Name Title
DepartmenUDivision
DepartmenUDivision
4. Verification
1 have ct~termind that it is in the interests of the agency to accept this gift and use it for the official agency business described above.
~.
f
,~ r' ~ ~ ~
~,/
r ~ ignaturo ofA,_ncy~iP4d~or Designee Print Name ~ ~ { _t 11~: e (month. ~da year)
Comment: (use this space or an attachment for any additional information.}
FPPC Form 801 {JunetO$}
FPPC Toll-Free Helpline: 866tASK-FPPC {866/275-3772}