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HomeMy WebLinkAboutROUGH FITGift to Agency Report 1. Agenc Name i ~- n-~ U S~ i n Division, D partment, or Region (if applica 1-~uma,~ ~:e.sowrce s 300 C~fie,~-~~ a I via ra Cod /Phone Number E-mail ~~ ~~(~ ~~3~3b~C envy Contact (name and title) ^ Amendment (explain in comment section) Date of Original Filing: (month, day, year) 2. Donor Name and Address ^ Individual Other ~I Last Name First Name Name I~~{-DI ~rov~~l~nq ~v~,- Saner[ ~~ C~ ~'2~c~~ Address City State Zip Code ~ it~~ess TrC~in ~ ~ ~ (if business) or its nature If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift: CO~nm~nni ~~~II~hC~lGiri~e~ (c~ 0 $ ame Amount Name Amount -___. 3. Payment Information Date and Amount of Payment (ornerrnan travel) ~ $ ~•~~ (m nth, day, year) (Round to whole dollars) Travel Payment Information (Round to whore dollars) 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: C-~if~ C21rt~~`iC fi~ ~~ wpr o~ Cr ©u~odr ~'rh~5s ~ro `I a~~~ ua1 ~h~r~ d~tv . ~ r~i ~ ~n ~ case ~.s a cu. l~ ~e cr~n e ~ ~ Identify the officials for whom the payment was used: Last Name First Name Last Name First Name Title Title DepartmentlDivision DepartmenttDivision __ 4. Verification 1 have determined that it is in the interests 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 Comment: (Use this space or an attachment for any additional information.) (month, day, year) A Public Document GIFT TO AGENCY REPORT Date Stamp ~ • ' • F T U S T I N For Official Use Only I U P 4~ Sb FPPC Form 801 (June/08) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)