HomeMy WebLinkAbout803 JR ROBERTS 2019-10-03 Modernism WeekBehested Payment Report
1. Elected Officer or CPUC Member (Last name, First name)
JR Roberts
Agency Name
B ehested Payment Report
California 803
Form
For Official Use Only
City of Palm Springs OF THE CITY CL ER
-=-A-g-en_c_y_s=-t,...re_e....,t--=Ac-d:-d,-re_s_s ________________ ____. ................ ""f""
3200 E. Tahquitz Canyon Way
Des ignated Conta ct Person (Name and title, i f different)
Anthony Mejia, C ity Clerk
Area Code/Phone Number E-mail (Optio nal)
760-323-8204
0 A mendment (See Part 5)
Date of Ori g i na l Filing: --,--,--,---,--
(month. day. year}
2. Payor Information (For additional payors, md ude an attachment with the names and addresses )
Modernism Week
Name
P.O . Box 5001 Palm Springs CA 92263
Address City Slate Zip Code
3. Payee Information (For additional payees, include an attachment with the names and addresses.)
City of Palm Springs
Name
3200 E . Tahqu itz Canyon Way
Address
4. Payment Information (Compl ete allinfonnabon.}
Date of Payment: __ 09_1_29_1_20_1_9_
(month, day. year}
Palm Springs CA 92262
City Slate Zip Code
100, 0()0 , <?2 Amount of Payment: (ln-KindFMVJ $ ----'---------
(Round to whole dollars.}
Payment Type : ~ Monetary Donation or D In-Kind Goods or Services (Provide descripbon below.}
Brief Description of In-Kind Payment: ------------------------------
PU rpose: (Check one and provide description below.} D Leg islative ~ Governmental D Charitable
Describe the legislative, governmental, charitable purpose , or event: Plaza Theat re Restoration Fund
5. Amendment Description and/or Comments
6. Verification
I certify, under penalty of perjury under the laws of the State of California , that to the st of my knowledg e, the information contained
herei n is true and complete.
2-:'iq Executed o n _I_L __ l _ __,,....,.L.f_.,,_ ___ _
DATE
FPPC Fo rm 803 (January/2018)
FPPC Toll-Free Hel p line: 866/ASK-FPPC {866/275-3772)