HomeMy WebLinkAboutZOV'S BISTRO, INC.Gift to Agency Report A Public Document
1. Agency Name
G~f o-~ Ti . -4i h ~- Tus-hr`-r ~ I ler Dau s
Divisi n, Department, or Region (if applicable) ~,
inn
Street Address
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Area CodetPhone Number E-mail
Agency Contact (name and title)
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2. Donor Name and Address
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Last Name First Name Na
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Address City State Zip Code
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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 (other than rraveq ~ ~l ~q $ ~ ~~°
(month, d y. year) (Round to whole dollars)
Travel Payment Information (Round to whole donors) Location of Travel
Date(s) of Travel $ ansportation 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
GIFT TO AGENCY REPORT
Date Stamp • • ,
•
T Y OF T U S T i N For Official Use Only
SEP - I A III 4
Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
Title
Title
Department/Division
DepartmenVDivision
4. Verification
1 have determined that it is in the interests of the agency fo accept this gift and use it for the official agency business described above.
C~w`~- ~u-••~ C~i~ S ~S'K:e Cl~e.(ai~.c~ ~ . ~rc~ier~j sez- ~/ 3 / o
Signature of Agency Head or Designee Print Name T le (m nth, day, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)