HomeMy WebLinkAboutCARTER, DIANEGift to Agency Report
1. Agency Name
City of Tustin
Division, Department, or Region (ifapplicab/e)
Street Address
300 Centennial Way, Tustin, CA 92780
A Public Document
(714) 573-3000 I cshingleton@tustinca.org
-gency Contact (name and title)
Christine Shingleton, Assistant City Manager
2. Donor Name and Address
GIFT TO AGENCY REPORT
Date Stamp,
For Official Use Only
^ Amendment (explain in comment secSon)
Date of Original Flling:
(month, day, year)
~ Individual Carter Diane ^ Other
Last Name First Name Name
Tustin CA 92780
Address City State Zip Code
If Other' is marked, describe the entity's business acUvrty (rf 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 man rra~eq 12/1/2010 $ $400.00
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dollar;) 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:
Identify the officials for whom the payment was used:
Last Name First Name
Last Name First Name
Title DeparlmenUDivision
Tiile DepartrnenUDivision
4. Verification
I have determined that it is in the interests of the agency to accept this gift and use it for the ofFcial agency business described above.
~..
~ Christine Shingleton Assistant City Manager 12/1/2010
ignature of Agency Hea Designee Print Name Title (month, day, year)
Comment: (Use this space or an attachment for any additional information.)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275.3772)