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Gift to Agency Report
1. Agency Name
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Divisi n, Department, or Repion,(ifapplicable)
A Public Document
GIFT TO AGENCY REPORT
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For Official Use Only
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Amendment (explain in comment section)
i~f Original Filing:
(month, day, year)
2. Donor Name and Address
^ Individual
~~ La Na e First
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Address ~ ,
',Other
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State
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If "Other° is marked, describe the entity's business activity In business) or its nature ana interests.
If applicable, ide ify the narpe of each source and the amount(s) solicited or received by the donor for this gift:
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~ ame S Amount Name Amount
3. Payment Information
Date and Amount of Payment (orherrnan rrsvel) ~
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole doaan;) 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:
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Identify the officials for whom the payment was used:
Last Name First Name Title
last Name First Name Title
DepartmenUDivision
4. Verification
1 have determined that it is i 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, yeah
Comment: (Use this space or an attachment for any additional information.)
DepartmenUDivision
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866IASK-FPPC (866/275-3772)