HomeMy WebLinkAboutSTATE FARM INSURANCEGift to Agency Report
1. Agency Name
City Of Tustin
Division, Department, or Regi
Parks and Recreation
Street Address
300 Centennial Way
Area Code/Phone Number
714/573-3326
Agency Contact (name and title)
Sarah King
A Public Document GIFT TO AGENCY REPORT
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^ Amendment (explein in comment section)
Sking@tustinca.org
Date of Original Filing:
(month, day, year)
2. Donor Name and Address
^ Individual
Last Name First Name
Name
3 State Farm Plaza Bloomington IL 61791
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 09/10/2010 $ 5000.00
(month, day, year) (Round to whole ddlars)
Travel Payment Information (Round to whore dalarsl 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
Last Name First Name
^x Other State Farm Insurance
TRIe
Title
DepartmenUDivision
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.
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.~ 'nature of Agency He d or esignee Print Name TRIe onth, ay, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June108)
FPPC Toil-Free HelpHne: 8661ASK-FPPC (8661275-3772)