803 Geoffrey Kors 2022-01-13 Eisenhower Medical CenterBehested Payment Report A Public Document ,
1. Elected Officer or CPUC Member (Last name, First name) CITY Of 6t;te bta��? 1
Kors, Geoffrey
Aaencv Name 7 JAH 18 Vil 1. 43
City of Palm Springs
3200 E. Tahquitz Canyon Way
(Name and title,
Area Code/Phone Number E-mail (Optional)
(760) 323-8299
2. Payor Information (Foreddn nal
�'_ ; l P, % gv(. / '--y
❑ Amendment (See Part 5)
Behested Payment Report
For Official Use Only
Date of Original Filing:
(month, day, year)
include an attachment with the names and addresses.)
City
3. Payee Information (For additional payees, include an attachment with the names and addresses.)
Boys & Girls Club of Palm Springs
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State Zip Code
Name
450 S Sunrise Way Palm Springs CA 92262
Address City State Zip Code
4. Payment Information (Complete aft information.)
Date of Payment: 12 Z 2 J I/ Amount of Payment: (In -Kind FMI9 $
(mdipth. day, year) (Round to whole dollars.)
Payment Type: j$'Monetary Donation or ❑ In -Kind Goods or Services (Provide description below)
Brief Description of In -Kind Payment:
Purpose: (Check one and provide description below.) ❑ Legislative ❑ Governmental 0 Charitable
Describe the legislative, govemmental, charitable purpose, or event:
Sponsorship of Annual Event Supporting Youth
5. Amendment Description and/or Comments
6. Verification
I certify, under penalty of pedury 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 / // r� / )�Z By
ATE
OFFICER OR CPUC MEMBER
FPPC Form 803 (January/2018)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)