HomeMy WebLinkAboutTUSTIN MATH CENTERGift to Agency Report A Public Document GIFT TO AGENCY REPORT
C I f I b`f`t'~' U S T
City of Tustin
Division, Deparuneni, or ircegion (~ appncaore/ I
Parks and Recreation
300 Centennial Way Tustin, CA 92780
(714) 573-333tp
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2. Donor Name and Addi
d~~
^ Individual
Last Name First Name
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Address ~~ty
or its nature
1009 J1lN 25 P
For OlBcial Use Only
25
^ Amendment (explain in comment seceion)
Date of Original Flling:
(month, day, year)
Other ~~ ~~ "'~ ~~~~~
Name !~ w~
Zip
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 (otherrnan travel) $
(morMh, day, year) (Round to whole dollars)
Travel Payment Information (Round ro wnae daiars) 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:
Identify the officials for whom the payment was used:
N/A
Last Name First Name
Last Name First Name
Title
DepartmentlDivision
Title Department/Division
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 P nt Name Tdle (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
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FPPC Form 801 (Junel08)
FPPC Toll-Free Helpiine: 8661ASK-FPPC (866/275-3772)