803 Geoffrey Kors 2022-05-05 PS DisposalBehested Payment Report
A Public Document
Type or Print in Ink.
1.Elected Officer or CPUC Member (Last name, First name) ELECTED OFFICER OR CPUC MEMBER: AGENCY NAME:
Amendment of FIiing D Check box if an Amendment
Gonth, Day, vLr)
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Date Stamp (Agency)
RECEIVED
MAY 5 2022
AGENCY STREET ADDRESS:
CALIFORNIA 803 FORM
Kors, Geoffrey 'city of Palm Springs 3200 E Tahquitz Canyon Way, Palm Springs, CA 92262 DESIGNATED CONTACT PERSON (NAME AND TITLE): f•MAIL: rREA CODE/PHONE NUMBER:
760-323-8299 geoff .kors@palmpringsca.gov
2.Payor Information (For additional payors, include an attachment with the names, addresses, and proceeding information)NAME: tADDRESS:
() ..S O 11 iJ, ft" f
D Donor Advised Fund (OAF) (see Instructions)
_OAF NA--JlfE:
BRIEF DESCRIPTION OF PROCEEDINGS: D Payor Is a named party or the subject of a proceeding before my agency.
3.Payee Information (For additional payees, Include an attachment with the names, addresses and relationship Information)NAME: ADDRESS:
Boys & Girls Club of Palm Springs 450 S. Sunrise Way
CITY:
Palm Springs
IZIP CODE:
'J)_]�
STATE: ZIP CODE:
CA 92262
For a nonprofit organization payee, provide a brief description of any relationship to the official, official's Immediate family member or staff member In the role of founder, salaried employee, decision-making capacity (board member or executive officer) or position on an honorary O_! advisory board. NAME AND TITLE: IROLE WITH THE NONPROFIT ORGANIZATION: IBRIEF DESCRIPTION:
Geoffrey Kors, President Board of Directors President Board of Directors Self
4.Payment Information (Complete all information. For estimated payment information check the box below.)DATE AMOUNT PAYMENT TYPE BRIEF DESCRIPTION OF IN-KIND PAYMENT PURPOSE DESCRIBE THE LEGISLATIVEE GOVERNMENTAL, (MONTH/DAY/YEAR) CHARITABLE PURPOS , OR EVENT:
Cf))t/)-]_ �ONETARY DONATION B LEGISLATIVE �t1Clo GOVERNMENTAL 0 IN-KIND GOODS OR SERVICES � CHARITABLE , -, 0 MONETARY DONATION -LEGISLATIVE : GOVERNMENTAL 0 IN-KIND GOODS OR SERVICES CHARITABLE REASON FOR ESTIMATE: D The (DATE/AMOUNT> Is an estimate and reflects my best efforts at obtaining the accurate
Information.
5.Amendment Description and/or Comments (Provide date of original filing or confirmation number in Part 1.)
6.Verification
Sponsorship of 2022 Fundraising Event
I certify, under penalty of perjury under the laws of the State of cailfomta, that knowledge, the information contained herein Is true and complete.
Executed on a � !Psi n ( DATE By z;<> < v SIGNAIORE FPPC Form 803 (February/2022) advice@fppc.ca.gov