HomeMy WebLinkAboutELITE SMILESGift to Agency Report A Public Document GIFT TO AGENCY REPORT
1. Agency Name { ~- ~. ~ ~~~~ ~. ~ ~~
•
City Of Tustin .
Division, Department, or Region (if applicable) For Official Use Only
ZQI ~~P 30 A ~~ ~
Parks and Recreation
Street Address
300 Centennial Way
Area Code/Phone Number E-mail
^ Amendment (explain in comment section)
714/573-3326 Sking@tustinca.org
Agency Contact (name and title) Date of Original Filing:
(month, day, year)
Sarah King
2. Donor Name and Address
^ Individual ~ Other Elite Smiles LLC
Last Name First Name Name
20062 SW Birch St #2220 Newport Beach CA 92660
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 Payment (other than o-aveq 09/03/2010 ~ 100.00
(month, day, year) (Round to whole ddlars)
Travel Payment Information (Round to whore dalars) Location of Travel
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:
Donation for Tustin Tiller Days
Identify the officials for whom the payment was used:
Last Name First Name Title Department/Division
Last Name First Name Title Department/Division
4. Verification
I have d rmined that t is in the interests of the agency to accept this gift and use it for the official agency business described above.
t '
-~ ~~ ~ [~ i~f: - ~ ~ ~ ~ a
ure ofAg ncy H d or Des' ne rint Na a '' ~~~ Title ( onth, ay, year)
Comment: (Use this space oiaan attachment for any additional information.)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpiine: 8661ASK-FPPC (8661275-3772)