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Gift to Agency Report A Public Document GIFT TO AGENCY REPORT 1. Agency Name Date Stamp a I ornia p O Form v Division, Department, or Region Of applicable) For Official Use Only Street Address Area Code /Phone Number E -mail Amendment (explain in comment section) Agency Contact (name and title) Date of Original Filing: (month, day, year) 2. Donor Name and Address Individual Other Last Name First Name Name 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 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 Oepartment/Divislon 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. Signature of Agency Head or Designee Print Name Title (month, day, year) Comment: (Use this space or an attachment for any additional information.) FPPC Form 801 (June /08) FPPC Toll -Free Helpline: 88 8/ASK -FPPC (888/275-3772)