HomeMy WebLinkAboutSANTAELLA, LUISGift t0 Agency Report A Public Document ctFrroAeertcrR~ottr
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Far Ott Use Only
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^ Amenc#swttt (explain in aornrnent ser~ion)
Date of Origins! Filing:
(~~, daf: Year)
2. Do or NameCa(nvd\Addre~s(',
Individual ~-1,1~~, ~tJ~- ~~\ ~ Q Othec'
Lest Name First Name Nan-e
Addre~ Cily State Zrp Cale
N "Other" b marked, deerxibe the erMlty's t>~iness activUy (i! bruiness) a its naGxe and intere:ls..
ff applicabt~eC,~(i/d~\entify the name of each soutrs and the amotmt(s) solicited or received lry the donor for this gifk
Natrle AmOUnt Name Amwrnt
3. Payment Information
Date and Amount of Payment (odrer then tra-er) $
(month. day, yeah (Round ro whoib dol~r71
Travel Payment Information (r~ra,ar to whore a~aarat Location of Travel
Date(s) d Trave! Trartsportatton F~pensa. $ L.«1gfnQ F~,sea ~ Med Expense. $ otfbr F~pe„aes $ total: Eupensee
Provide a specific description of the nature and use of the payment for official agency business:
Identify the officials for wttarrt the payment was useck
Last Name First Name Title DepartmerM/Division
Last Name First Name rUe
Depertrnartt/Division
4. Verification
I have determined that it is in the interests of the agency b accept this giR and use it for the offrciat agency business described above.
Signature otAgency Head a Designee Prirrt Name Tito (maith, day, years
COn'tril@nt: (Use this space or an attachment for any additYor-at informatio--.)
Date Stamp
FPPC Form 804 (June/ti8)
FPPC Toli-Free Helpiine: 866fit3K-FPPC (866/25-3772)