HomeMy WebLinkAboutKAPLANGift to Agency Report A Public Document GIFT TO AGENCY REPORT
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zaaR fa~aR 2 u a i i: o
For Otlkial Use Only
^ Amsndmsttt (explain In comment section)
and title)
2. Donor Name and Address
^ Individual
Dais of Original Filtng:
(month, day, year)
[other ~'1C~(~ Y1
.. ~ Name
Date and Amount of Payment (other than navel) $ -
(month, day, year) (Round ro whole doNars)
Travel Payment Information (Rasa ro wnob daiars) Location of Travel
Date(s) ~ Travel firansportation 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
Last Name First Name
Titb
Depertment/Divislon
TitN Department/Division
4. Verification
I have determined that it is in the i rests of the agency to accept this gift and use it for the official agency business described above.
Signature d Agenq Head a Despnee Print Name Titb (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (Jutts/08)
FPPC Toll-Free Helplins: 886IASK-FPPC (8681278-3772)
If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift:
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Name Amount Name ~ Amount
3. Payment Information