801 Payment to Agency Report (Wafu School of Ikebana) 03-01-23Payment to Agency Report
1. Agency Name
City of Cupertino
DiVi8iOn, Department, Or Region (ifapplicable)
City Manager's Department
Street Address
A Public Document
4 0300 Torre Avenue
Area Code/Phone Number Email
408-777-3223 cityclerk@cupertino.org
Agency COmaCt (name and title)
Kirsten Squarcia, City Clerk
FAYMENT TO /.GENCY REPOFT
Fc al ape C nly
MAR 1 a'23
uate of Original Filing:
(month, day, year)
2. Donor Name and Address
01 ndivirliim jiOther
LastName FirstName
Cupertino
Address City
School for Japanese art of floral arranging
If "Other" is marked, describe the entity's business activity (if business) or its nature and interests.
Wafu School of Ikebana, California Chapter
Name
CA 95014
State Zip Code
% If ':ipplicable, identify the name of each source and the amount(s) received by the donor for this payment:
Fusako Hoyrup .'p 300
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)
Transportation Provider
IJ Rail 0 Air [3 Bus 0 Auto [1 0ther
Check Applicable Boxes
$ $
Lodging Expenses Meal Expenses
3.1 (b) Payment(s) not related to travel:
Transportation Expenses Other Expenses
Dates (momh, day, year)
Name of Lodging Facility
Total Expenses
Total Expenses
3.2. Payment Description. Provide a specific description of the payment and its agency purpose and use.
Flower Arrangement Donation for display at City of Cupertino State of the City event on 2/1 5/23
3.3. Identify the officials who used the payment in Section 3.1 (See instructions)
Last Name First Name Position/ntle Department/Division
Last Name First Name Position/Title
4, Verification
I authorized the acceptance of the reported payment(s) as in compliance with FPPC regulations.
/"ahu4-(l'u- PamelaWu CityManager
Signature PrintName Title
Comment:
(Use this space or an attachment for any additional information)
Department/Division
Feb 25, 2023
(month, day, year)
FPPC Form 801 (Jan/l 8)
advice@fppc.ca.gov
801 Payment to Agency Report
Final Audit Report
Created:
Bat:
Status:
Transaction ID:
2023-02-23
Kirsten Squarcia (kirstens@cupertino.org)
Signed
CBJCHBCAABAAULusexUUB-BZS7G9elqvnffUspcgRCqM
2023-02-25
'1801 Payment to Agency Report" History
'5 Document created by Kirsten Squarcia (kirstens@cupertino.org)
2023-02-23 - 6:01:'19 PM GMT- IP address: 67.188.176.248
R Document emailed to Pamela Wu (PamelaW@cupertino.org) for signature
2023-02-23 - 6:03:43 PM GMT
'5 Email viewed by Pamela Wu (PamelaW@cupertino.org)
2023-02-25 - 8:24:07 PM GMT- IP address: '104.47.74.'l26
#@ Document e-signed by Pamela Wu (PamelaW@cupertino.org)
Signature Date: 2023-02-25 - 8:24:35 PM GMT - Time Source: server- IP address: 73.231.186.149
@ Agreement completed.
2023-02-25 - 8:24:35 PM GMT
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