801 Payment to Agency Report - Cupertino Hotelc'y of Cupe"no j(i D EC 2 "- 2023 4": "JClfflcial us.e CnlyDiVt8tOn, DeparmenI Or Regton (ifapplicable)
City Manager's Office
StreetAddress UUHLRTINOCITYC.LERK
10300 Torre Avenue
AreaCode/PhoneNumberEmail [lAmendment(expiain:ncommentseciion)
408-777-3225 kirstens@cupertino.org
Agency Contact (name and title) Uate of Original Filinq:
Kirsten Squarcia,City Clerk (mom' day' yaar)
2. Donor Name and Address
ll'ldivirli ih
Last Name
Address
First Name
Cupertino
City
8 0ther
Cupertino Hotel
CA
State
Name
95014
Zip Code
Commercial establishment that offers lodging, food, and other services For travelers
If "Other" is marked, describe the enfity'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:
't;.200.00 ,,
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 (momh, day, year)
Transportation Provider
% Rail [1 Air g Bus [] Auto [3 0ther
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.
Beverage and service donation for all attendees of the Cupertino Swearing-in-Ceremony held on
12/'14/23.
3.3. Identif'/ the Off!CtalS WhO used the paymem !n S €3CttOn 3.1 (See instructions)
Last Name First Name Position/Title Department/Division
Last Name First Name Position/Title [)epartment/Division
4. Verification
ed the acceptance of the reported payment(s) as in compliance with FPPC regulations.
Pamela Wu City Manager
Print Name Title
Com
(Use this space or an attachment for any additional information)
12/21/23
(month, day, year)
FPPC Form 801 (Jan/18)
advice@fppc.ca.gov
Payment to Agency Report
Instructions a A Public Document
I
This form is user to repo'rt certain, payments received by"itate and local Part 1. Agency Identification
government agencies. It includes: List the agency's name and address and the name of an agency contact.
a paymentfor an official's travel expenses forthe purpose of Mark the amendment box if changing any information on a previously
facilitatingthepublic'sbusinessinlieuofapaymentusingagency fi'ledformandincludethedateoftheoriginalfi'ling.
funds; and Part 2. Donor Information
apaymentthatwouldotherwisebeconsideredagiftorincome Disclosethenameandaddressofthedonor. Ifthedonorisnotan
tothebenefi'ti'ngofh'cial,butisinsteadacceptedonbehalfofthe individual,identifythebusinessactivityornatureandinterestsofthe
agency. entity.
FPPC Regulations 18944 and 18950.1 provide a procedure that state
and local agencies may use to disclose payments used for agency
purposes and paid by a third party. The regulations' reporting
procedures provide an alternative means to disclose a payment
that may otherwise be considered income or a gift to a benefitting
employee and subject to reporting on a Statement of Economic
Interest, Form 700.
When and Where to File
An agency accepting a payment pursuant to Regulation 18944
and 18950.1 must complete Form 801 for each payment received
regardless of the amount. The form must be maintained as a public
document. If payments aggregate"2,500 or more in a calendar
quarter, website posting is required.
Website Posting:
State Agencies
Within 30 days after the end of a calendar quarter if aggregated
reported payments, for travel and non-travel purposes, total S2,500 or
more:
the agency must post the reports (or a report summary) on the
agency website; and
forward the information to the FPPC which will also post the
information,
Local Agencies
The website posting rules differ for travel and non-travel payments.
Travel
Within 30 days after the end of a calendar quarter if aggregated
reported payments total S2,500 or more:
the agency must post the reports (or a report summary) on the
agency website; and
forward the information to the FPPC.
Payments Not Related to Travel
The agency's f'ling officer for Statement of Economic Interests, Form
700, must receive the report. Within 30 days after the end of a
calendar quarter if ag(4regated reported payments total S2,500 or
more, the local agency must post the information on the local agency
website. A report is not sent to the FPPC unless the agency does not
have a website.
Postings must be displayed in a prominent manner and easily
accessible. Reports may be posted earlier.
FPPC: Statements should be emai)ed to form80l@fppc.ca.gov.
Statements may also be mailed to 1102 Q Street, Suite 3000,
Sacramento, CA 95811 or faxed to (916) 322-3711.
If the donor received funds from other sources that were used in
connection with the payment, disclose the name and payment
information for each source.
Part 3. Payment Information
Expenses may be rounded to whole dollars.
Section 3.l.a. ltemize travel payments including departure and return
dates. Complete all fields, use "n/a" appropriately. Total the expenses
for items such as taxi rides, gratuities, and rental cars in the "other"
field and describe in the comments section.
Section 3.l.b. Report agency payments that are not travel related.
Section 3.2. Description
All payments must include a specific description of the use of the
payment and the intended purpose for agency business. For example,
a travel payment may read: Travel to attend an EPA co-sponsored solar
energy seminar in Washington o.c.
Section 3.3. Identify Officials
Travel Payments: The name of the position/title and department of
each official who used the payment is required. List the official's name
if he/she is an elected or appointed official. It is not required to list the
names of other officials, rather insert "n/a." Do not leave blank.
Non-Travel Payments: The name, position/title and department of the
agency official who used the payment must be identified. All officials'
names are required.
Part 4. Verification
Verification of travel payments must be signed by an authorized agency
official. Such individuals are those who have the authority to approve
similar travel payments when made with agency funds.
Verif'cation of non-travel payments must be signed by the agency head.
FPPC Form 801 (Jan/l 8)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)