801 - Disneyland
City Clerks Public
801 - Disneyland
3/14/2018 2:29:10 PM
3/14/2018 2:29:00 PM
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Payment to Agency Report A Public Document <br />1. Agency Name <br />City of Brea <br />Division, Department, Or Region (if applicable) <br />Fire Department <br />Street Address <br />1 Civic Center Circle <br />Area Code/Phone Number Email <br />714-990-7757 1 firstname.lastname@example.org <br />Agency Contact (name and title) <br />Lillian Harris -Neal <br />2. Donor Name and Address <br />❑ Individual <br />Last Name First Name <br />P.O. Box 3232 Anaheim <br />Address City <br />Date Stamp <br />PAYMENT TO AGENCY REPORT <br />For Official Use Only <br />❑ Amendment (explain in comment section) <br />Date of Original Filing: <br />(month, day, year) <br />r1 Other Walt Disney Company <br />Amusement Park <br />If "Other' is marked, describe the entity's business activity (if business) or its nature and interests. <br />Mame <br />CA 92803 <br />State Zip Code <br />�ow If applicable, identify the name of each source and the amount(s) received by the donor for this payment: <br />Name Amount <br />Name <br />Amount <br />3. Payment Information (Complete Sections 3.1 (a or b), 3.2, 3.3) <br />3.1 (a) Travel Payment <br />Location of Travel Dates (month, day, year) <br />❑ Rail ❑ Air ❑ Bus [:]Auto ❑ Other <br />Transportation Provider Check Applicable Boxes Name of Lodging Facility <br />Lodging Expenses Meal Expenses Transportation Expenses $ Other Expenses Total Expenses <br />3.1 (b) Payment(s) not related to travel: 2-14-2018 $ 14,696.00 <br />Dates (month, day, year) Total Expenses <br />3.2. Payment Description. Provide a specific description of the payment and its agency purpose and use. <br />Tickets given in appreciation of fire services provided to the state during recent wildfire. <br />3.3. Identify the officials who used the payment in Section 3.1 (see instructions) <br />See Attached <br />Last Name First Name Position/Title <br />Last Name <br />First Name <br />Department/Division <br />Position/Title Department/Division <br />4. Verification <br />I a tho ' e e tan of the reported paym t(s) as in co pI' nce with FRPC regu tions. <br />�%1r fiS� 1 1 ZDI� <br />Signature rint Name I Title th, dal, year) <br />Comment: <br />(Use this space or an attachment for any additional information) FPPC Form 801 (Jan/18) <br />email@example.com <br />
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