803 Christy Gilbert Holstege 2019-09-18 Contour Dermatology and Cosmetic Surgery CenterBehested Payment Report A Public Ddai>iltED
Behested Payment Report
1. Elected Dfflcer or CPUC Member (Last name, First name)
Date Stamp
• : ,
Christy Gilbert Holstege
5 )8
PM
For Official use orgy
Agency Name
City of Palm Springs OFFICE OF THECITY
CLER:
Agency Street Address
3200 E Tahquitz Canyon Way
Designated Contact Person (Name and title, if diflenint)
❑ Amendment (see Pad S)
Christy Gilbert Holstege
Date of original Filing:
(monM, day, yew)
Area Code/Phone Number
E-mail (optional)
(760) 323-8299
christy.holstege@palmspdngsca.gov
2. Payor Information (For additional payors. include an attachment with the names and addresses)
Contour Dermatology and Cosmetic Surgery Center
42600 Mirage Road Rancho Mirage CA 92270
Address city stet. Zip Code
3. Payee Information (Far additional payees, include an attachment with the names and addresses.)
Equality California
Name
3701 Wilshire Blvd, Suite 725 Los Angeles CA 90010
Address city state Zip code
4. Payment Information (Can,plet. all lnramatlon.)
Date of Payment: 8/20/2019 Amount of Payment: (m.(indFMv) $ 5,000
(mont), day, yead (Round to whole dollars.)
Payment Type: ® Monetary Donation or ❑ In -Kind Goods or Services (Provide description aelow)
Brief Description of In -Kind Payment:
Purpose: (Checkonearldpmmdedescripliondelow) [I Legislative ❑Governmental ®Charitable
Describe the legislative, governmental, charitable purpose, or event: Equality California Palm Springs Awards
event to take place in October 2019
5. Amendment Description and/or Comments
6. Verification
I certify, under penalty of perjury under the laws of the State of Califomia, that to the best of my knowledge, Hte information contained
herein is true and complete. _ n
Executed on 9/9/2019 By /�
DATE SIGNATURE OF ELECTED OFFICER OR CP MEMBER
FPPC Form 803 (January/2018)
FPPC Tollfree Helpline: 866/ASK-FPPC (866/275-3772)