HomeMy WebLinkAboutState Farm InsuranceGift to Agency Report
1. Agency Name
City of Tustin
Division, epartment, or Vagion (ifappllcabl
Tustin Police Department
treetAd reu
300 Centennial Way, Tustin, CA 92780
A Public Document
(714) 573 -3300 1 saftken @tustinca.org
Shannon H. Aitken, Executive
GIFT TO AGENCY REPORT
MIDM`C�9IE 0 V • •
r OMdal Use Only
JUL 2 3 2014
TUSTIN
CITY CLERK'S OFFIC
❑
Amendment (explain in mmmentsec6'on)
Date of Original Filing:
(—M, day, year)
❑ Individual ® Other State Farm Insurance
Last Name Fhst Name Name
17802 Irvine Blvd, #121 Tustin CA 92780
Address City state Zip Code
Insurance Company
I' Other' is marked, describe the entity's business activity (N 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:
Nana $ Amouru Name Amount
3. Payment Information
Date and Amount of Payment (oMxMen naveii 07 -14 -2014 $ 100.00
(monM, day, year) (Round to whole dollars)
Travel Payment Information (Round to whole dousrs) Location of Travel
Data(s) or Travel re� nsporutlon Even $ LodO:q Expert— $ Meal Expenses $ oth« Expenses $ Taal Fxpenaee
Provide a specific description of the nature and use of the payment for official agency business:
Donation to the Tustin Police Department Santa Sleigh program.
Identify the officials for whom the payment was used:
Last Name First Name Title DeparmanUDFnelon
Last Name First Name - Title DepertmerAMMafon
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.
_ Charles F. Celano, Jr. Chief of Police 07/2212014
aAOeooy Nead or Designee Print Name Tice (Month, day, year)
Comment: (Use this space or an attachment for any additional Information.)
FPPC Form 801 (June/08)
FPPC Toll -Free Hslpllne: 866/ASK-FPPC (88612763772)