HomeMy WebLinkAboutSUNWEST BANKGift to Agency Report
1. Agency Names
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bivision. enartment. or Region (if aq
A Public Document
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GIFT TO AGENCY REPORT
Date Stamp
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Amendment (explain rn comment seceon)
Date of Original Filing:
(month, day, year)
2. Donor Name and
^ Individual 15~~Other }~~ ~~~ ~~ ~'
Last Name First Name J~ Name
Address v Cky 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 (otherrhan travel) 3 ~~ ~ ~ $
(r onth, day, year)
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(Round to whole dollars)
Travel Payment Information (Round to whole donors) Location of Travel
Date(s) of Travel Transportafion F~cpenses ~ Lodging Expenses ~ RAeal 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
DepartmentlDivision
Lasf Name First Name Title DepartmentlDivision
4. Verification
t have determined that it is in the interests of the agency to accept this gift and use it for the oft±cial agency business described above.
Signature of Agency He D signee Print Name Title month day, year)
Comment: (Use this space or an attachment for any additional information,)
FPPC Form 801 (June108j
FPPC Toll-Free Hetpline: 866lASK-FPPC (86&1275-3772)