Laserfiche WebLink
California <br />Form <br />Agency Report of: <br />1. Agency Name <br />Designated Agency Contact (Name,Title) <br />Date Stamp <br />E-mail <br />Division, Department, or Region (if applicable) <br />2. Function or Event Information <br />Verification <br />I have read and understand FPPC Regulations 18944.1 and 18942. I have verified that the distribution set forth above, is in accordance <br />with the requirements. <br />Signature of Agency Head or Designee Print Name <br />Comment: <br />FPPC Form 802 (2/2016) <br />FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) <br /> (month, day, year) <br />802 <br />(month, day, year) <br />For Official Use Only <br />Area Code/Phone Number <br />Date of Original Filing: <br />Ticket(s)/Pass(es) provided by agency? <br />Was ticket distribution made at the behest <br />of agency official? <br />Title <br />Ceremonial Role Events and Ticket/Pass Distributions <br />Face Value of Each Ticket/Pass $ <br />Event Description: <br />If no: <br />If yes: <br />Amendment (Must Provide Explanation in Part 3.) <br />Provide Title/ Explanation <br />Name of Source <br />Official’s Name (Last, First) <br />If checking “Ceremonial Role” or “Other” describe below: <br />If checking “Ceremonial Role” or “Other” describe below: <br />Name of Agency, Department or Unit <br />Name of Outside Organization <br />(include address and description) <br />Name of Individual <br />(Last, First) <br />Number <br />of Ticket(s)/ <br />Passes <br />Number <br />of Ticket(s)/ <br />Passes <br />Number <br />of Ticket(s)/ <br />Passes <br />Describe the public purpose made pursuant to the agency’s policy <br />Identify one of the following: <br />Describe the public purpose made pursuant to the agency’s policy <br />Does the agency have a ticket policy?No <br />No <br />Income Other <br />Other <br />Ceremonial Role <br />Ceremonial Role Income <br />No <br />Yes <br />Yes <br />Yes <br />Date(s) // // <br />3. <br />A. <br />B. <br />C. <br />4. <br />A Public Document <br />Recipients <br />Use Section A to identify the agency’s department or unit. Use Section B to identify an individual. Use Section C to identify an outside organization.• • •