HomeMy WebLinkAboutROUGHFIT, INCGift to Agency Report A Public Document c+FrTO~c~NCYRePORT
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Divis on, epartment, or 12egion (dapplicatNe).
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Date Stamp
For Ofrrcial Use Only
^ Amendment (explain in commerrt section)
(name and
2. Donor Name an
^ Individual i~Qgt~
Last Name First Name
of Original Filing:
(month, day, year)
tt -txner" is rrrarlred, describe the entity's tnisirtess adiv' - -
dy (if txrsiness) a its nature and arterests.
('I~f a~ppt`icabte, identify the name of each source and tChe(~amourrt(s) solicited or received hY the donor for this gift:
Name Arm,rK ~t~..,e . ~..~
3. Payment information
Date and Amount of Payment Comer rnan traael) $
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round ro whore donars) t.ocation of Travel
Date(s) of Travel Transportation Ercpenses ~ Lodging 6cpenses $ Meal Expenses $ Other Expenses $ Total Expensee
Provide a specific description of the nature and use of the payment for official agency business:
Identify the officials for whom the paymerrt was used:
Last Name First Name Title Department/Oivision
Last Name First Name Title De}~artmenUDivision
4. Verification
I have determined that it is in the interests of the agency to accept this gift and use rt for the official agency business described above.
Signature of Agency Head or Designee Print Name Title (month, day, year}
Comment: (Use this space or an attachment fur any additionaf infnrmatiorr.)
FPPC Form 801 (June/Q8)
FPPC Toli-Free Heiplina; 8661ASK-FPPC (886/Z75-3772)