HomeMy WebLinkAboutRoma D'ItaliaGift to Agency Repoli A Public Document GIFT TO AGENCY REPORT
1. Agency Name
Date Stamp
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For Official Use Only
ivi i , Department, or Region (if applicable)
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OCT 2 5 2012
TICE- TUSTIN CITY CLERK
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Amendment (explain m comment section)
to of Original Filing:
(month, day, year)
Agency Con (name and title)
2. Donor Name and Address
❑ Individual
If "Other" is marked, describe the entity's business activity (if business) or its nature and interests.
Other
If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift:
Fornapry%,�'a a I Co $
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (other than travel) $
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dollars) Location of Travel
Date(s) of Travel h. sponabon 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
Department/Division
4. Verification
I 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.
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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 Toll -Free Helpline: 8661ASK -FPPC (86612753772)