HomeMy WebLinkAboutState Farm Auto InsuranceGift to Agency Report A Public Document GIFT TO AGENCY REPORT
1. Agency Name
City of Tustin
MAY 15 2012
For Official Use Only
Division, Department, or Region (if applicable)
Parks and Recreation
OFFICE- TUSTINCMCLfR
Street Address
300 Centennial Way, Tustin, CA 92780
Area Code /Phone Number
E -mail
❑ Amendment (explain in comment section)
714 - 573 -3326
Dwilson @tustinca.org
Date of Original Filing:
Agency Contact (name and title)
(month. tlay, year)
David Wilson, Director Parks and Recreation
2. Donor Name and Address
❑ Individual ❑x Other State Farm Mutual Automobile Insurance Co
Last Name First Name Name
3 State Farm Plaza Bloomington IL 61791
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:
Name $ Amount Name $ Amount
3. Payment Information
Date and Amount of Payment (other than travel) 04/07/2012 $ 438.00
(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:
2012 Concerts in the Park Sponsorship
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
/ 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.
Sarah King Recreation Coordinator 5/14/12
Signature of ead 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 Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772)