HomeMy WebLinkAboutDOMINGUEZ, MIGUELGift to Agency Repart
1. Agency Name
City of Tustin
Division, Department, ar Reg
street Address
300 Centennial Way, Tustin, CA 92780
tirea Code/Phone Number E-mail
(714) 573-3010 ~ cshingleton@tustinca.org
lgency Contact (name and title)
Christine Shingleton, Assistant City Manager
2. Donor Name and Address
A Public Document
CITY OF ~US~ Stamp
(if applicable) n ~ Q
100q MAY - Y`
GIFT TO AGENCY REPORT
For Official Use Only
^ Amendment (explain in comment section)
Date of anginal Filing:
(month, day, year)
^x Individual Dominguez Miguel ^ Other
Last Name First Name Name
Tustin CA 92780
Address City State Zip Code
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:
Name ~ Amount Name ~ Amount
3. Payment Information
Date and Amount of Payment (otnarrhan rravep 5/5/09 $ $400.00
(month, day year) (Round to whole dollars}
Travel Payment Information (Round to whom aarars) 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:
Library Donation
Identify the officials far whom the payment was used:
Last Name First Name Title DepartmentlDivision
Last Name First Name Title Department/Division
4. Verification
1 have determined that it is in the interesfs of the agency to accepf fhis gift and use it for the official agency business described above.
Christine Shingleton Assistant City Manager 5/5/09
~~~ n ure of Agenc ead or Designee Print Name Title (month, day, year)
Comment: (Use dais space or an attachment For any additional information )
FPPC Form 807 (June/08)
FPPC Toll-Free Heipline: 866/ASK-FPPC (8661275-3772)