HomeMy WebLinkAboutMILAM CHIROPRACTICGift to Aaencv Resort A Public Document GIFT TO AGENCY REPORT
. Agency Name
C~~-y~~TUs~in -Ti~s-1tr~~ftlle~r
Division. Department. or Region of applicable)
34v Cesn~xm~•\
~~i~-5~3 - 33~
Agency Contact (name and title)
C1~Y1Sfi+~e. Cl~~,lav~d..
2. Donor Name and Address
s
Date Stamp
CITY ~ I' T U 5 T I P~ For Official Use Only
1009 SEP - I A III ~~y
^ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
^ Individual ~,] Other ~~\~`~'~- willrblfJrC~c~1 ~
Last Name First Name Name
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 (other than rraveq g ~` ~~ $ ~~~ a-~'~ ~
( onth, day. year) (Round to whole dollars)
Travel Payment Information (Round to whole dorrars) 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:
Last Name First Name Title DepartmenUDivision
last Name First Name Title
DepartmenUDivision
4. Verification
t have determined that it is in the interests of the agency to accept this gift and use if for the official agency business described above.
~Z2,at~ ~~~- Cht~s~ue C£-eti~ela.t~( ,~?~crer,~$firn ~-/-v~r~. ~' a~ v
Signature of Agency Head or Designee Print Name Title ° (month, day, year)
COt7lnlent: (Use this space or an attachment for any additional information.)
us~~ ~3~ ~
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866IASK-FPPC (866!275-3772)