HomeMy WebLinkAboutNAYAB CHIROPRACTICGift to Agency Report A Public Document GIFT TO AGENCY REPORT
1. q ency Name
Divlsi ,Department, or Region (if applicable) For Official Use Onfy
1 200 AP - 2 ,4 ~~ 31
Street Address ~ (~
". ~ V~
rea Code/Phone Number E-mail
,~ ~~ ,..~.,1 `~ ~ Amendment (explain in comment section)
Agency Contact (name and title) ate of Original Filing:
f1~J'~/`~ ~ ~~~~~ ~~(~ ~(~~ (month, day, year)
2. Donor Name and Address
^ Individual
Pr (~. Pic
If "Other" is marked, describe the entity's business activity (if business) or its nature and interests.
~~ appiicaoie, laentiry 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 (otnerthan rraveq $
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dotlars) Location of Travel
Date(s) of Travei 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
I 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 Print Name
C.Or1lfYlent: (Use this space or an attachment for any additional information.)
Title
(month, day, year)
~~
FPPC Form 801 (June/08)
FPPC Tott-Free Helpline: 866/ASK-FPPC (8681275-3772)