HomeMy WebLinkAboutHONDA YAGift to Agency Report
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Division. Department. or Reaion if as
A Public Document
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Area Code/Phone Number
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Agency Contact (name and til
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2. Donor Name and Address
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Last Name First Name
Address City
GIFT TO AGENCY REPORT
Date Stamp
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( For Official Use Ooly
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Amendment (explain in commentsection)
Date of Original Filing:
(month, day, year
Name
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If "Other" is marked, describe the entity's business activity (if business) or fts nature and interests.
If applicable, identify the name of each source and the amount(s) solicited or received by the danar for this gift:
Name $ Amount Name $ Amount
3. Payment Information (`~
Dat@ and ArnOUnt Of Payment (other than travel) ~ ~ ~ ~ ~ ~ ~ ~ L/ ~~
(month, ay, year) (Round to whole dottars)
Travel Payment information (Round to whole dottars) Location of Trave!
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
Last Name First Name
Title
Tifle
DepartmentlDivision
Department/Division
4. Verification
1 have determined that ft is in the interests of the agency to accept this gift and use it far the official agency business described above.
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Signature o
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COn1Clleflt: (Use this space or an aftachmenf for any additions! information.)
FPPG Form 801 (June108)
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