HomeMy WebLinkAbout803 JR ROBERTS 2019-10-03 Palm Springs Preservation FoundationBehested Payment Report
1 . Elected Officer or CPUC Member (Last name, First name) Date Stamp
JR Roberts CT : 3 PH \2 : 3 2 ~A-ge_n_c_y_,,N,..,.a_m_e ______________________ _..,
City of Pa lm Sprin gs OF THE CITY CLE Ri
Agency Street Address
3200 E . Tahqu itz Canyon Way
Behested Payment Report
California 803
Form
For Official Use Only
Designated Contact Person (Name and title, if different)
Anthony Mejia, City Clerk
D A mendment (See Part 5)
Area Code/Phone Number E-mail (Optiona l)
760-323-8204
Date of O rig i nal Filing: -------,--
(month, day. year)
2. Payor Information (For additional payors, include an attachment with the names and addresses.)
Palm Springs Preservation Foundation
Name
1775 E . Palm Canyon Drive, Suite 110-195 Palm Springs CA 92264
Address City State Zip Code
3 . Payee Information (For additional payees, include an attachment wi th the names and addresses )
City of Palm Springs
Name
3200 E. Tahquitz Canyon Way Palm Springs CA 92262
Address City State Zip Code
4. Payment Information (Complete all information.)
Date of Payment: __ 0_61_0_6_12_0_1_9_
(month, day, year)
Amount of Payment: (In-Kind FMVJ $ 50 ,000.00
--(=Ro-u-nd.,...,t-o w--,h,-ol,_e -,do/....,,la-rs--,.)---
Payment Type : [gJ Mon etary Donation or D In-Kind Goods or Services (Provide descnp tfon below}
Brief Description of In-Kind Payment: _____________________________ _
Purpose: (Check one and provide description below.) D Legislative [gJ Governmental D Charitable
Describe the legislative, governmental, charitable purpose, or event: Plaza Theatre Rest orat ion 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 best of my knowledge, the information contained
h erein is true and complete.
Executed on ------=-,~----
DATE
-
FPPC Form 803 (January/2018)
FPPC Toll -Free Hel pline: 866/ASK-FPPC (866/275-3772)