HomeMy WebLinkAboutGSC GATEWAY, LP (2)Gift to Agency Report
1. Agency Name
6ivision, DepartrrzenS~, car Region (i l c, ~~~~,'~;)
street r~dd~ress
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Area CodelPhone Number E-mail
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A Public Document
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GIFT TO AGENCY REPORT
For Official Use only
^ Amendment (explain in comment section)
Date of Original Filing:
s ~ trnumn, uay, yea~~
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2. Donor blame and Address
v
^ Individual '~~?the; ~ ~ ~ ~ .t
Last Name First Name Name
~ '
ri #
address ~ ~ City State Zip Code
It her" is marked, describe tl 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 Ai1'IOUnt Of Payment (other than travel) $
(month, day, year) (Round fo whole dottars)
Travel Payment information (Round to whore douars) Location Of Travel
$ $ $ $ $
Date{sj 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 Title Department/Division
Last Name First Name Title Department/Division
4. Verification
/have determined that it is in the interests of fhe agency to accept this gift and use if for the official agency business described above.
'S '` fr t - l t '-
Si nature a~fA-c~~c neap orD~sl nes~ Print Name Title
g y y g (month, day year)
C01'T1rY12nt: (Use this space or an attachment for any additional information.)
FPPC Form 8d1 {Junett38}
FPPC TaII-Free Helpline: 8661ASK-FPPC (8661275-3772}