HomeMy WebLinkAboutJACOBS, MICHAEL (2)Gift to Agency RE
1. Agency Name
City of Tustin
Division, Department,
Police Department
Street Address
300 Centennial Way
Area Code/Phone Nun
714 573-3396
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A Public Document
GIFT TO AGENCY REPORT
Date Stamp • +~
ss • ~
or Region (if applicable) ~ ~ i ~' ~ ~ 1 ~ For Official Use Only
18 A q~ 5 5
Iber E-mail
^ Amendment (explain in comment section)
rortiz@tustinca.org
Agency Contact (name and title)
Ruby Ortiz :Police Services Officer
2. Donor Name and Address
Date of Orlglnal Filing:
(month, day, year)
~ Individual Jacobs Michael ^ Other
Last Name First Name Name
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:
Michael Jacobs $ 100.00
Name Amount
Name
Amount
3. Payment Information
Date and Amount Of Payment (other than travel) $
(month, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dollars) 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:
Funds were used for the Walk to School Program.
Identify the officials for whom the payment was used:
Last Name First Name
rtie
Last Name First Name 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.
~t ~ / ~~~ , ~ ~ ~ Scott M. Jordan
Signature of Agen Head or Designee Print Name
Comment: (Use this space or an attachment for any additional information.)
Chief of Police
rrtie
1-5-11
(month, day, year)
FPPC Form 801 (June/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)