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HomeMy WebLinkAbout801 Form Parks & Rec - Donations to Senior Center - Various DonorsPayment to Agency Report A Public Document 1. Agency Name City of Cupertino Division, Department, or Region (if applicable) Parks and Recreation Street Address C 10300 Torre Ave., Cupertino CA 95014 Area Code/Phone Number Email 408-777-3225 laurens(a�cupertino.gov Agency Contact (name and title) Lauren Sapudar, City Clerk 2. Donor Name and Address Date Stamp RECEIVED SEP 01 2026 'ERTINO CITY Cl PAYMENT TO AGENCY REPORT For Official Use Only ❑ Amendment(explain in comment section) Date of Original Filing: (month, day, year) ❑ Individual Various donors ❑ Other Last Name First Name Name Address City State Zip Code Monetary donations. If "Other" is marked, describe the entity's business activity (if business) or its nature and interests If applicable, identify the name of each source and the amount(s) received by the donor for this payment: (See attached itemized list) $ $ Name Amount Name Amount 3. Payment Information (Complete Sections 3.1 (a or b), 3.2, 3.3) 3.1 (a) Travel Payment Location of Travel Dates (month, day, year) ❑ Rail ❑ Air ❑ Bus ❑ Auto ❑ Other Transportation Provider Check Applicable Boxes Name of Lodging Facility $ $ $ $ $ Lodging Expenses Meal Expenses Transportation Expenses Other Expenses Total Expenses 3.1 (b) Payment(s) not related to travel: $ Dates (month, day, year) Total Expenses 3.2. Payment Description. Provide a specific description of the payment and its agency purpose and use. Donations to Senior Center in memory of former member, Lee Lederer. 3.3. Identify the officials who used the payment in Section 3.1 (See instructions) Last Name First Name Position/Title Department/Division Last Name First Name Position/Title Department/Division 4. Verification I authorized the acceptance of the reported payment(s) as in compliance with FPPC regulations. Tina Kapoor City Manager Tina Kapoor(Sep 1.2026120226 09/01/2026 PDT) Signature Print Name Title (month, day, year) Comment: (Use this space or an attachment for any additional information) FPPC Form 801 (Jan/18) advice@fppc.ca.gov Dorothy Johnson Monetary Donation $50 Dee Crawford Monetary Donation $50 Regina F. Shirley Monetary Donation $50 CA Form 801 Final Audit Report Created: 2026-09-01 By: Melissa Robertson (melissar@cupertino.gov) Status: Signed Transaction ID: CBJCHBCAABAAJSb8QGIai-EhM5pONMLKxdfOVwn-FmT4 "CA Form 801" History Document created by Melissa Robertson (melissar@cupertino.gov) 2026-09-01 - 5:56:43 PM GMT E Document emailed to Tina Kapoor (TinaK@cupertino.gov) for signature 2026-09-01 - 5:56:47 PM GMT Email viewed by Tina Kapoor (TinaK@cupertino.gov) 2026-09-01 - 5:57:26 PM GMT 2026-09-01 6© Document e -signed by Tina Kapoor (TinaK@cupertino.gov) Signature Date: 2026-09-01 - 7:02:26 PM GMT - Time Source: server - Signature Appearance Selected: DRAW a Agreement completed. 2026-09-01 - 7:02:26 PM GMT Q Adobe Acrobat Sign