2019-02-22 Mizell Senior Center Stars Among Us GalaAgency Report of
Ceremonial Role Events and Ticket/Pass Distributions A Public Document
1. Agency Name Date Stamp • '
City of Palm Springs nnin Li'
Division, Department, or Region (if applicable) kR 20 Ai'i 3 For Official Use Only
Christina Chartier, Executive Assistant
❑ Amendment (Must Provide Explanation in Part 3.)
760-322-8366 I christina.chartier@palmspringsca.gov I Date of Original Filing: (month, day, year)
2. Function or Event Information
Does the agency have a ticket policy? Face Value of Each Ticket/Pass $ 500.00
9 Y Y� Yes ® No ❑
Event Description: Mizell Senior Ctr Stars Among Us Gala Date(s) _21-1 22) 1 g9 1
Provide Title/Explanation
Ticket(s)/Pass(es) provided by agency? Yes ❑ No ® If no: Mizell Senior Center
Name of Soume
Was ticket distribution made at the behest Yes ❑ No ® If yes:
Official's Name (Lest, First)
of agency official?
3. Recipients
• 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.
Number
A. Name of Agency, Department or Unit
of Ticketls)l
Describe the public purpose made pursuant to the agency's policy
Passes
B. Name of Individual
Number
of Ticket(s)I
Identify one of the following:
(Last, First)
Passes
Ceremonial Role ❑ Other ❑ Income ❑
Holstege, Christy
2
Public du'rpos$ aes- fdetinaede6y"Oel° esoiuiion No. 22454,
Sect. 1(d)(iii)(vii)(viii)
Ceremonial Role ❑ Other ❑ Income ❑
Perotti, Robert
Public Purepaose as a fined �iy'P§ esbTu> If No. 22454,
Sect. 1(d)(x)
Name of Outside Organiution
C.
Number
of Ticket(s)l
Describe the public purpose made pursuant to the agency's policy
(Include address and description)
Passes
4. Verification
I have read and under
with the requirements.
Comment:
Regulations 18944.1 and 18942. I have verified that the distribution set forth above, is in accordance
Print Name Title (month, day, year)
FPPc Form 802 (2/2016)
FPPC Toll -Free Helpline: 8661ASK-FPPC (8661275.3772)
Agency Report of: California 802
Ceremonial Role Events and Ticket/Pass Distributions Form
Continuation Sheet A Public Document
Agency Name
City of Palm Springs
3. Recipients
• 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.
Number
A. Name of Agency, Department or Unit
of Ticket(s)l
Passes
Describe the public purpose made pursuant to the agency's policy
B. Name of Individual
(Last, First)
Number
of Ticket(s)/
Passes
Identify one of the following:
Mills, Chris
2
Ceremonial Role ❑ Other ® Income ❑
It checking 'Ceremonial Role" or `Other" describe below:
ublic Purpose as defined by PS Resolution No. 22454,
ect. 1(d)(iv)(xi)
J u ras ky, Jeff
2
Ceremonial Role ❑ Other ® Income ❑
If checking 'Ceremonial Role' or 'Other' describe below.
Public Purpose as defined by PS Resolution No. 22454,
Sect. 1(d)(iv)(xi)
Boyd, Stephen
2
Ceremonial Role ❑ Other ® Income ❑
It checking `Ceremonial Role"or `Other" describe below:
Public Purpose as defined by PS Resolution No. 22454,
Sect. 1(d)(iv)(xi)
Ceremonial Role ❑ Other ❑ Income ❑
If checking 'Ceremonial Role'or "Other' describe below.
Name of Outside Organization
C.
(Include address and description) p )
Number
of Ticket(s)1
Passes
Describe the public purpose made pursuant to the agency's policy
FPPC Form 802 (212016)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772)