803 Geoff Kors 2019-09-10 Goodwin Family Memorialtsenestea Payment Keport A PU0IlC uo"
Behested Payment Report
1. Elected Officer or CPUC Member (Last name, First name) CITY OF
PALMa&RRkNGS
• '
Kors, Geoff
0 AM 10: 4 2
For Official Use Only
Agency Name
Palm Springs City Council
THE CITY CLER.
Agency Street Address
3200 E. Tahquitz Canyon Way
Designated Contact Person (Name and title, if different)
❑ Amendment (See Part 5)
Date of original Filing:
(month, day. year)
Area Code/Phone Number
E-mail (optional)
7605370061
2. Payor Information (For additional payors, include an attachment with the names and addresses)
Goodwin Family Memorial
100 N Main Street, 6th Floor, MAC D4001-065 Winston-Salem NC 27101
4ddress City State Zlp Code
3. Payee Information (For additional payees, include an attachment with the names and addresses.)
Boys & Girls Club of Palm Springs
450 S. Sunrise Way
Palm Springs
CA 92262
Address City State Zip Code
4. Payment Information (Complete allinrormabon.)
Date of Payment: 08/20/19 Amount of Payment: (10-kindFMV) $ 5,900
(month, day. year) (Round to whole dollars.)
Payment Type: 0 Monetary Donation or ❑ In -Kind Goods or Services (Provide descnpbon balow.)
Brief Description of In -Kind Payment:
Purpose: (Check one and prowde descnpeon below) ❑ Legislative ❑ Governmental 0 Charitable
Describe the legislative, governmental, charitable purpose, or event:
Grant for Passport to Manhood Program.
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
herein is true and complete. /
Executed on 09/08/19 By
DATE SIGNATURE OF ELECTED OFFICER OR CPUC MEMBER
FPPC Form 803 (January/2018)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)