HomeMy WebLinkAboutTHAI SPECIALTY 2Gift to Agency Report
1. A ency Name
Divis o ,Department, or egion (ifap
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Street Address ~ ~ ~
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Area Code/Pho ~e Number E-mail
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Agency Contact (name and title)
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2. Donor Namp and ndd~pgs
^ Individu
Address
A Public Document
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GIFT TO AGENCY REPORT
For Official Use Only
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^ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
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:
$ • 4~ $
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (ornerrnan vaveq _ _ $
(month, day, yeah (Round to whole dollars)
Travel Payment Information (Round to whole douars) 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:
T,,,~ ~ 25 . Ga 9 i ff ccrfi f 'cafes received -F~ r Chit y's ~a 1 fh ~e f fs ~Q,cr,
Identify the officials for whom the payment was used:
Last Name First Name- Title Department/Division
Last Name First Name Title DepartmenUDivision
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 Asency Head or Designee riot Name Title (month, siay, year)
COrnment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpllne: 866/ASK-FPPC (866/27b-3772)