HomeMy WebLinkAboutUS BankGift to Agency Report A Public Document GIFT TO AGENCY REPORT
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2. Donor Name and Address
Individual
If'Other is marked, describe the entity's business activity (if business) or its nature and interests
Date Stamp
RECOVED
OCT 2 5 2012
CITY CLERK
For Official Use Only
Amendment (explain in comment section)
of Original Filing:
(month, day, year)
If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift:
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Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (otherthan 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:
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
I have determined that it is in the of the agency to accept this gift and use It for the official agency business described above.
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Signature of Agency Head or Designee Print Name Tire (month, day, year)
Comment: (Use this space or an attachment for any additional intormation )
FPPC Form 801 (June/08)
FPPC Toll -Free Helpline: 866/ASK-FPPC (86612753772)