HomeMy WebLinkAboutUEHARA, HR. & GRACEGift to Agency Report
1. Agency Name
City of Tustin
Division, Department, Or Region (ifappticabte)
Street Address
300 Centennial Way, Tustin, CA 92780
(714) 573-3010 I cshingleton@tustinca.org
lgency Contact (name and title)
Christine Shingleton, Assistant City Manager
2. Donor Name and Address
CiiY G
100 i= Es
I U S[ia~e Stamp
P -~~ 3b
^x Individual Uehara H.R. and Grace ^ Other
Last Name First Name Name
Tustin CA 92782
Address City State Zip Code
!f "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:
Same as above ~ 400.00 ~
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (other than traval) $
(month, day year) (Round to whole doltars)
Travel Payment Information (Round to whore aonars) 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 far whom the payment was used:
Last Name First Name
Last Name First Name
Title
Title
GIFT TO AGENCY REPORT
For Official Use Only
Department!Division
DepartmenL`Division
4. Verification
I have determined thaf it is in the interesfs of the agency to accept Phis gifr and crse it for the official agency business described above.
Christine Shingleton Assistant City Manager 2/2/09
ignature of Agency ea or Designee Print Name Title (month. day, year)
Comment: (use ais space or an attachment for any additional information.)
A Public Document
^ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
FPPC Form 801 (June/08)
FPPC Toll-Free Heipline: 866/ASK-FPPC {866!275-3772)