HomeMy WebLinkAboutTUSTIN FAMILY CHIROPRACTICGift to Agency Report
1. Agency Name
City of Tustin
Division, Department, or Reg
Parks and Recreation
A Public Document
On (if applicable}
Street Address
300 Centennial Way
Area Code/Phone Num
(714) 573-3326 ~ SKing@tustinca.org
agency Contact (name and title)
Sarah King, Recreation Coordinator
2. Donor Name and Address
Date Starrp
GIFT TO AGENCY REPORT
For Official Use Only
Amendment (explaJn in comment section)
Date of Original Filing:
(month, day, year)
^ Individual ~ Other Tustin Family Chiropractic
Last Name First Name Name
13771 Newport Avenue #8 Tustin CA 92780
Address City State Zip Code
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 Paymentlernerrnan raver) 7/1/2010 ~ 75.00
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round ro whore dona~s) Location of Travel
Date(s) of Travel $ ansportation 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:
Sponsorship far 2010 Movies in the Park
Identify the officials for whom the payment was used:
Last Name First Name Title
Last Name
Title
Department/Division
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.
r
~ Sarah King Recreation Coordinator 8/27/10
Signature of Agency Hea or esignee Print Name Title (month, day, year)
COllllllent: (Use this space or an attachment for any addRronal information.)
DepartmenV'Division
FPPC Form 801 (June/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)