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HomeMy WebLinkAboutJACOBS, MICHAELGift to Agency Report 1. Agency Name City of Tustin Division, Department, or Region (lf POlice Department Street Address 300 Centennial Way Area Code/Phone Number E-ma 714 573-3396 (rortiz@tustinca.org Agency Contact (name and title) Ruby Ortiz :Police Services Officer 2. Donor Name and Address A Public Document GIFT TO AGENCY REPORT Date Stamp CITY C~ r ~`5 For Official Use Only Z~il .SAN 18 A 9~ (5 S Amendment (explain in comment section) Date of Original Filing: (monfh, 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 Name $ $200.00 $ Amount Name Amount 3. Payment Information Date and Amount of Payment (ornerrnan 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 Santa Cop Program. Identify the officials for whom the payment was used: Last Name First Name Title DepartmendDivision 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. ~f ~ ~~~~ ~~ ,~ ~ Scott M. Jordan Chief of Police 1-5-11 Signature of Age y Head or Designee Print Name Idle (month, day, year) Comment: (Use this space or an attachment for any additional information.) FPPC Form 801 (June/08) FPPC Toll-Free Helpllne: 866IASK-FPPC (866/275-3772)