2016-09-14 Hospitality Association Clubs Fore KidsAgency Report of:
Ceremonial Role Events and Ticket/Pass Distributions
1. Agency Name C E I YDEtIstamp
City of Palm Springs %I i 1 C)F PALM SPF:tNIG
or
Office of the City Manager
III
Designated Agency Contact (Name, Title) �` {[ " OFFICE
Cindy Cairns, Executive Services Administrator V _
Area Code/Phone Number E-mail
760-322-8362 1 cindy.cairns@palmspringsca.gov
26 AM IQ: 45
A Public Document
For Official Use Only
TLE CI i Y CLE,
❑ Amendment (MustProvide Explanation in Pan 3)
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 $ 175.00
g Y P Y� Yes® No
Event Description: PS Hospitality Assoc Clubs Fore Kids Date(s) 91 14 r 16 _ 1
Provide Tithe/Explanation
Ticket(s)/Pass(es) provided by agency? Yes ® No ❑ If no:
Name of Source
Was ticket distribution made at the behest Yes ❑ No ® it yes:
Official's Name (Last, 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 Ticket(sN Describe the public purpose made pursuant to the agency's policy
Recess
Number
�. Name of Individual of Ticket(sy Identify one of the following:
(Last, First) I passes
Mills, Chris
Kleindienst, Will
Ceremonial Role ❑ Other ❑X Income ❑
1 it checking 'Ceremonial Rote" or "Other' describe below:
Public Purpose as defined by PS Resolution No. 22464
Ceremonial Role ❑ Other ❑X Income ❑
1 if checking "Ceremonial Role" or `Other descnbe below;
Public Purpose as defined by PS Resolution No. 22454
Name of Outside Organization Number
C. of Tickegsy Describe the public purpose made pursuant to the agency's policy
(include address and description) Passes
4. Verification
1 have read and understand
with the requirements. r
Comment:
18944.1 and 18942. 1 have verified that the distribution set forth above, is in accordance
David Ready City Manager
Print Name Title (month, day, year)
FPPC Form 8021212016)
FPPC Toll -Free Helpline: 8661A5K-FPPC (6661275-3772)
Agency Report of:
Ceremonial Role Events and Ticket/Pass Distributions Form U
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 TickegsY
Passes
Describe the public purpose made pursuant to the agency's policy
B. Name of Individual
(Last, First)
Number
of Tlckegsy
Passes
Identify one of the following:
Jurasky, Jeff
Ceremonial Role ❑ Other El Income ❑
ltchecking"CerenronialRoie"or"Otheh'descnbebeiow:
Public Purpose as defined by PS Resolution No. 22454
Fontana, Mike
1
Ceremonial Role ❑ Other El Income ❑
lfchecking "CerenronialRole" or"Othae'dascnbebelow:
Public Purpose as defined by PS Resolution No. 22454
Ceremonial Role ❑ Other ❑ Income ❑
If checking "Ceremonial Role" or `other describe below:
Ceremonial Role ❑ Other ❑ Income ❑
if checking 'Ceremonial Role" or "Other' describe below.
Name of Outside Organization
C. g
(include address and description)
Number
of Tickeasy
Passes
Describe the public purpose made pursuant to the agency's policy
FPPC Form 802 (2t2016)
FPPC Toll -Free Helpline: 8661ASK-FPPC (866/275-3772)