HomeMy WebLinkAboutCalifornia Pizza KitchenGift to Agency Report
1. Agency Name
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Street Add rose
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2. Donor Name and Address
❑ Individuai
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Address
A Public Document
GIFT TO AGENCY REPORT
RELtI'+�ED
For Official use Onty
NOV 19 2013
TUSTIN CITY CLERK
❑ Amendment (sxpiain in comment section)
Data of Original Filing:
(monm, dey. yead
❑ Other
Name
If'Other" is marked, descritm the entity's business activity (if business) or its nature and interests.
Zip Code
If applicable, identify the nam�ej of each source and the amount(s) solicited or received by the donor for this gift:
C�- 1 !/t/� , 1 i�+ 1 $
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (omerman travel) $
(monm, day. ;;7r—) (Round to whole doRera)
Travel Payment I nformation (Rwnd to Wt** domars) Location of travel
Dates) of Travel $ansportabw Expenses $ Lodging Expenses Meal Expenses $ 0ther 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 Tide DepartmenVDNision
Lest Name First Name Title Departmenvomsion
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.
Signature of Agency Head a Designee Print Name Title
(rrranth, day, yeed
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June=)
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