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Tickets Provided by <br /> Agency Report A Public Document TICKETS PROVIDED BY <br /> AGENCY REPORT <br /> 1. Agency Name Date Stamp California 802 <br /> Form C7 <br /> Division, Department, or Region (if applicable) For Official Use Only <br /> Street Address <br /> Area Code /Phone Number E -mail <br /> Amendment (Must explain in Part 5.) <br /> Agency Contact (name and title) Date of Original Filing: <br /> (month, day, year) <br /> 2. Event For Which Tickets Were Distributed <br /> Date(s) of Event: —J —J— Description of Event: <br /> Face Value of Ticket: <br /> Agency Event Yes No (Identify source of tickets below.) <br /> Name of Outside Source of Ticket(s) Provided to Agency: <br /> Number of Tickets Received: Ticket(s) Provided to Agency: Gratuitously Pursuant to Contract <br /> 3. Agency Official(s) Receiving Ticket(s) (use a continuation sheet for additional names) <br /> Name of Official Number State Whether the Distribution is Income to the Official or <br /> (Last, First) of Tickets Describe the Public Purpose for the Distribution <br /> 4. Individual or Organization Receiving Ticket(s) (Provided at the behest of an agency official.) <br /> Name of Behesting Agency Official: <br /> Name of Individual or Organization: Number of Tickets: <br /> Description of Organization: <br /> Address of Organization: <br /> Number and Street City State Zip Code <br /> Purpose for Distribution: (Describe the public purpose for the distribution to the organization.) <br /> 5. Verification <br /> I have determined that the distribution of tickets set forth above is in accordance with the provisions of FPPC Regulation 18944.1. <br /> Signature of Agency Head or Designee Print Name Title (month, day year) <br /> Comment: (Use this space or an attachment for any additional information including amendment explanation.) <br /> FPPC Form 802 (Feb /09) <br /> FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275 -3772) <br />