HomeMy WebLinkAboutIndependence BankGift to Agency Report A Public Document GIFT TO AGENCY REPORT
1. Agency Name
- • '
JUL 11 2013
For Official Use Only
iviS. , Department, or Region (if applicable)
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OFFICE - TUSTIN CITY C
ERK
Street Address
( NA)6,13 33a�
Area Code /Phone Number
I E -mail
❑ Amendment (explain in comment section)
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Date of Original Filing:
Agency Contact (name and title)
(month, day, year)
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2. Donor Name and Address (gyp
❑ Individual Other �
Last Name First Name Name
ROrX � C:a. 421Q'S-E
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) $
(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:
Identify the officials for whom the payment was used:
Last Name First Name
4. Verification
Title
Department/Division
Department/Division
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 Agecy Head or Designee Print Name Tide (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 (866/275 -3772)