HomeMy WebLinkAboutWATTERS, LORIGift to Agency Report
1. Agency Name
sion, Department, or Region {if applicable)
treet Address
rea CodelPhone Num
ency Contact (Warne anti title)
GIFT TO AGENCY REPORT
For Official Use Only
[~ Amendment (explain rn comment section)
date of Original Filing:
(month, day, year)
2. Donor Name and Address
Individual ^ Other
Last f~iame First 'Jame hlame
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)
(month, day, year) (Round to whole dollars}
Travel Payment Information (Round ro wnole aotlars} Location of Travel
Dates} of Travel ~ansportation 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 far whom the payment was used:
Last Name First Name
Title
Department(Division
Last Name First Name Title DepartmentlDivision
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.
Signature of Agency Head or Designee print Name Title (month, day, year)
COmmertt: {Use this space or an attachment for any additional information.}
A Public Document
Date Starnp
FPPC Form 801 (June108)
FPPC Toll-Free Helpline: 866lASK-FPPC (866!275-3772)