HomeMy WebLinkAbout803 JR ROBERTS 2019-10-03 Darryl PonicsanBehested Payment Report
1. Elected Officer or CPUC Member (Last name, First name} Date stam p
JR Roberts 9 CT : 3 PM \2: 3 2 ..,.A-ge_n_c_y_N...,..a_m_e ____________________ ___.,.,....~
City of Palm Springs OF FIC OF THE CITY CLE R'
Agency Street Address
3200 E. Tahquitz Canyo n Way
Des ig nated Contact Pers on (Name and title, if different}
Anthony Mejia, C ity Cle rk
D Amendment (See Part 5)
Area Cod e/Phone Number E-ma il (Optional} Date of Ori gi nal Filing : ______ _
760-323-8204
2 . Payor Information (For additional payors, include an attachment with the names and addresses.}
Darryl Ponicsa n
Name
2982 Searchlig ht Ln . Palm Spri ngs
Address City
3. Payee Information (For additional payees, include an attachmen t with the names and addresses.}
C ity of Pal m Sprin gs
Name
3200 E. Tahqu itz Canyon W ay Pal m Springs
Address City
(month. day, year)
CA 92264
State Zip Code
CA 92262
Stat e Zip Code
4. Payment Information (Complete all information.)
Date of Payment: -.,...0_91_0_51_2_0_1_9-,--
(month. day, year)
Amount of Payment: (fn-KindFMVJ $ 25 ,00 0.00 ----,(R=o-u-nd.,..to_w_,h_o/,....e ...,..do/...,la_rs...,.) __ _
Payment Type: IB] Monetary Donati on or D In-Kind Goods or Services (Provide descripbon below.)
Brief Description of In-Kind Payment: _____________________________ _
Purpose: (Check one and provide descripHon below.) D Legislative IBl Governmental D Charitable
Describe the legislative, governmental, charitable purpose, or event: Plaza T heatre Restoration Fund
5. Amendment Description and/or Comments
6 . Verification
I certify, under penalty of perjury und er the laws of the State of California, that to t he best of my knowled ge, t he information contained
herein is true and complete.
Exec uted on __________ _
DATE
FPPC Fo rm 803 (January/2018)
Toll-Free Helpline: 866/ASK·FPPC {866/275-3772)