HomeMy WebLinkAboutGSC GATEWAY, LPGift to
1. Agen
,17epartment, or i
rt A Public Document GIFT TO AGENCY REPORT
IT,.
(if applicable) ~ -f iI For Official Use Only
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I1(CA \IVVC/r IIVIt6 1\VIIIY61 V'IIIOI
Q ^ Amendment (explain in comment section)
Agency Contact name and tle) 1, Date of Original Filing:
(month, day, year)
'~ " ', n ~~,fl, \, , ~
2. Donor Name and Address 1 yl
^ Individual Other `-~~1y ~-~"~~~'\~~1~ , ~~
Last Name First Narrle Nam
Address Cdy State Zip Code
~~~~~~ E;tU~ew ~~,~'~1~~~1 ~ ~~~~~~,~`.,
~If "Other' is marked, describe the entity's bus ess activity ('rf business) or its natufe and interests.
If applicable, identify the name of each source and the amou/nt(s) solicited or received by the donor for this gift:
$ ~ ~~ ~J ~ C.~ ~ ~
Name Amount Name $ Amount
3. Payment Information
Date and Amount of Payment (ornerrnan travel) $ .
(month, day, year)
Travel Payment Information (Round to wnole donors) Location of Travel
(Round to whole dollars)
Date(s) of Travel TranspoAation 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 for whom the payment was used:
Last Name First Name
last Name First Name
Title
Title
DepartmenUDivision
DepartmenUDivision
4. Verification
I have determined that it is in th~i terests of the agency to accept this gift and use it for the official agency business described above.
Signature of Agency Head or Designee Print Name Title (month, day, year)
Comment: (Use this space or an attachment for any additional inlormation.)
FPPC Form 801 (June/08)
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