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Gift to Agency Report A Public Document GIFT TO AGENCY REPORT
1-Agency Name � " Date Stamp a i ornia 801
Q. Q vsk\t' OK k 4 ). rQ� RECEIVE[sC�G�dC Form
ivl n, Department,or Region (if applicable)' For Official Use Only
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Street Address
`'6 G.I z 33kS1- OFFICE-TUSTIN CITY CLE-IK
Area ode/Phone Number E-mail
❑ Amendment(explain in comment section)
UmOoNSVaLI.
Agency Contact(name and title) ate of Original Filing:
(month,day year)
2. Donor Name and Address (�
❑Individual ther R'1`4l'V) t VI\&
Last Name Firstt Naame
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OS
Address State Zip Code
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If"Other is marked,descn a he s business iviry(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:
R'ms aiGa $\,5eol co $
Na 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 Title Department/Division
Last Name First Name Tile 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.
•
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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:866/ASK-FPPC(8661275-3772)