2017-05-12 United Way Moulin Rouge GalaAgency Report of:
Ceremonial Role Events and Ticket/Pass Distributions
1. Agency Name
City of Palm Springs
Division. Department. or Region (ifawlicable) .�
Designated Agency Contact (Name,Title)
Christina Chartier, Executive Assistant to Mayor and Council
760-322-8366 1 christina.chartier@paimspringsca.gov
2. Function or Event Information
Does the agency have a ticket policy? Yes ® No ❑
Event Description: United Way Moulin Rouge Gala
Provide Trtfe/Explanation
Ticket(s)/Pass(es) provided by agency? Yes ® No ❑
411c Document
"Lh1 SPit' 1s
For off dal
AUG 10 PIS 3: 3
E Ul- T,iL {_.i I Y G�
❑ Amendment (Must Provide Explanation in Part 3.)
Date of Original Filing:
(month, day, year)
Face Value of Each Ticket/Pass $ 280.00
Date(s) 5t 12 l 17 -1
If no:
Name of Source
Was ticket distribution made at the behest Yes ❑ No ® If yes:
orr
of agency official? aarsName lLasr, First)
3. Recipients
• Use Section A to identify the agency's department er 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(sy Describe the public purpose made pursuant to the agency's policy
Passes
Number
B. Name of Individual of Ticket(s)l Identify one of the following:
(Last First) pas"
Moon, Robert Ceremonial Role ❑ Other IN Income ❑
1 h checking 'Ceremonial Role" or •Other" doacrlbe below,
Public Purpose as defined by PS Resolution No. 22454
Ceremonial Role ❑ Other ® Income ❑
if checking 'Ceremonial Role- or `Other" describe below:
Name of Outside Organization Number
C (include address and description) of Tickosil Describe.the public purpose made pursuant to the agency's policy
Passes
4. Verification
1 have read and understand FPPC Regulations 8944.1 and 18942. i have verified that the distribution set forth above, is in accordance
ents.
DZ
9 ure of Agen ad or Designee Print Name Tdle (month, day, year)
Comment:
FPPC Form 802 (2120161
FPPC Toll -Free Helpline: 8661ASK-FPPC 18661275-3772)