HomeMy WebLinkAboutHERDEG, BERYL ANNGift to Agency Report
1. Agency Name
City of Tustin
Division, Department, or Region (If applicable)
A Public Document
GIFT TO AGENCY REPORT
Date Stamp
For Official Use Only
300 Centennial Way, Tustin, CA 92780
-rea Code/Phone Number E-mail
(714) 573-3000 cshingleton@tustinca.org
-gency Contact (name and title)
Christine Shingleton, Assistant City Manager
2. Donor Name and Address
~ Individual Herdeg Beryl Ann
Last Name First Name
^ Amendment (explain in comment section)
Date of Original Firing:
(month, day, year)
^ Other
Name
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 Payment (other than travel) 12/1/2010 $ $400.00
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whore dollars) Location of Travel
Dates of Travel Trans rtation $ $ $ $
() po 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 Title DepartmenUDivision
Last Name First Name Title DepartmenUDivision
4. Verification
/ 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.
/~~ //
Christine Shingleton Assistant City Manager 12/1/2010
Signature of Agency Hea r signee Print Name Title (month, day, year)
C01711T1ent: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpllne: 866/ASK-FPPC (866/275-3772)