HomeMy WebLinkAboutPEI WEI ASIAN DINERGift to Agency Report
1. A ency Name
D tsio ,Department, or Region (if a
300 n~enn i(~l
Street Address nn
add.
Area Code/ ho ie Number E-mai
6 2m~
Agency Contact (name and title)
I ~~ sti r~chia . Di
2. Donor Name and Address
^ Individual ._
(month, day, year)
Ii "Other" is marked, describe the entity's business activity (A business) or its nature and imerosts.
If applicable, identify the name of each source and'tDhe amount(s) solicited or received by the donor for this gift:
Name $ Amount Name ~ Amount
3. Payment Information
Date and Amount of Payment (otherrnan travel) $
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dolars) Location of Travel
Date(s) of Travel ransportation Expanses $ Lodging Expenses $ Meal Expenses $ Other Expenses $ Total Expenses
Provide a specific description of the nature and use of the payment for official agency business:
~i x $10 •`~ gift- Cards received fir Gt~'s Nea If h Benp f its ~.~^.
Identify the officials for whom the payment was used:
Last Name First Name Tdle DepaRmenUDivision
Last Name First Name
rile
DepartmenUDivision
4. Verification
I have determined that it is in the interests of the agency fo accept this gift and use it for the official agency business described above.
sti ~.ecc is Qi.~~~--N~r~n_1~scurr~ ~~/3/~
Signature of Agency e d o esignee Print Name Title (month, day, year)
COmml?nt: (Use this space or an attachment for any additional information.)
A Public Document
GIFT TO AGENCY REPORT
ryr, ~ For ONiclal Use Only
1. a P iz~ r
Amendment (explain in comment section)
Date of Original Flling:
FPPC Form 801 (June/08)
FPPC Toll-Free Helpllne: 866/ASK-FPPC (866/275-3772)