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Gift to Agency Report A Public Document GIFT TO AGENCY REPORT <br />1. Agency Name <br />Division, Department, or Region (if appficable) <br />Street Address <br />Area Code/Phone Number E•mall <br />Agency Contact (name and title) <br />2. Donor Name and Address <br />D Individual -..--------------------Last Name First Name <br />Address City <br />D Other <br />Date Stamp California 8 0 1 Form <br />For Official Use Only <br />0 Amendment (explain in comment section} <br />Date of Original FIiing: ---,--,----- <br />(month, day. year) <br />Name <br />State Zip Code <br />If 'Other" is marked, describe the entity s bus'ness activity (if business) or its nature and lnlerests. <br />If applicable, identify the name of each source and the amount(s) solicited or received by the donor for this gift <br />Name $, ______ Amount -------,----------$, _______ Ame.urn <br />3. Payment Information <br />Date and Amount of Payment (other than travel} <br />(month, day. year) $ ----...-...,... ............ ----(Round to whole dollars) <br />Travel Payment Information (Round to whole dollars) Location of Travel ------------------- <br />Date(s) of Travel fransportation Expenses $ Lcdging Expenses $ Meal Expenses $ Other Expenses $ Total Ex, <br />Provide a specific description of the nature and use of the payment for official agency business: <br />Identify the officials for whom the payment was used: <br />Last Name First Name nue Department/Division <br />Last Na/llQ First Name Ti e Departmenl/0� <br />4. Verification <br />I have determined that it is in the interests of the agency to accept this gift and use it for the officiaf agency business described above. <br />Signature of Agency Head or Deslgnee Print Name <br />Comment: (Use this space or an attachment far any additional information.) <br />Title (month, day. year) <br />FPPC Form 801 (June/OB) <br />FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) <br />City of Brea <br />City Clerk's Office <br />1 Civic Center Circle, Brea, CA 92821 <br />(714) 990-7757 <br />Lillian Harris-Neal, City Clerk <br />09 08 2017 <br />California Pizza Kitchen <br />1065 Brea Mall Ste 2052a, Brea, CA 92821 <br />California Pizza Kitchen <br />$200.00 <br />Lillian Harris-Neal City Clerk 09/18/2017