HomeMy WebLinkAboutJaponaise Bakery, Inc.Gift to Agency Report A Public Document GIFT TO AGENCY REPORT
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For Offival Use Only
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OCT 26 2012
OFFICE- TUSTIN CITY
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Date f Original Filing:
(month, day, year)
Agency Conta t (ne a an title)
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2. Donor Name and Address I �/�z
❑Individual W Vther�J�O�`J\��Y
Last Name First Name TTTj� Name
Address City State Zip Code
If "Other' is marked, describe the entity's business activity (if businessi 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
U WM �(M $ o otm $
Name Amount Name Amount
3. Payment Information
Date and Amount of Payment (other than travep $
(month, tlay, year) (Round to whole dollars)
Travel Payment Information (Round to whole dollars) Location of Travel
$ $ $ $ $
Dates) 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
Last Name First Name
DepartmentlDimsion
Department/Division
4. Verification
/have determined that it is In the In re s of the agency to accept this gift and use it for the official agency business described above.
UgAWAgrency ead or Designee Print Name Title (month, day, year)
Comment' (Use this space or an attachment for any additional information)
FPPC Form 801 (June/08)
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