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HomeMy WebLinkAboutKIWANIS CLUB OF TUSTIN (2)Gift to Agency Report A Public Document GIFrTOAGENCYREPORT 1. Agency Name City of Tustin Police Department >treet Address 300 Centennial Way -rea Code/Phone Nun or 714 573-3396 -genCy Contact (name and title) rortiz@tustinca.org Ruby Ortiz :Police Services Officer Z. Donor Name and Address Date Stamp ~~~~ ~ ~ a a~ ss For Official Use Only ^ Amendment (explain in comment secfr'on) Date of Original Flling: (month, day, year) ^ Individual ©Other Kiwanis Club of Tustin Last Name First Name Name P.O. BOX 514 Tustin CA 92781 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: Kiwanis Club of Tustin $ $495.00 Name Amount Name Amount 3. Payment Information Date and Amount of Payment (ornBrrnan travel) $ (month, day, year) (Round to whole dollars) Travel Payment Information (Round to whole doaar;) 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 oft tcials for whom the payment was used: Last Name First Name rtie Department/Division Last Name First Name Title Department/Division 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. r ~~ ~, d" ; ~ Scott M. Jordan Chief of Police 1-5-11 Signature of Agegi Head or Designee Print Name Idle (month, day, year) i Comment: (Use this space or an attachment for any additional information.) FPPC Form 801 (June/08) FPPC Toll-Free Helpllne: 866IASK-FPPC (8661275-3772)