801 Payment to Agency Report - Pineapple Thai RestaurantPayment to Agency Report
1. Agency Name
City of Cupertino
DtVtStOn, Deparkmem, Or Region (ifapplicable)
City Manager's Office
Street Address C JPERTINO CITY CLERK
10300 Torre Avenue
Area Code/Phone Number Email
408-777-3225 kirstens@cupertino.org
Agency COmaCt (name and title)
Kirsten Squarcia,City Clerk
2. Donor Name and Address
0 Amendment (explain in comment section)
uate of Original Filing:
(month, day, year)
0 Indivirliim § Other
Pineapple Thai Restaurant
Last Name First Name Name
Cupertino 95014
Address City State Zip Code
Restaurant business that prepares and serves food and drinks onsite and takeout
If "Othei' is marked, describe the emity's business activity (if business) or its nature and interests.
If "ipplicable, identify the name of each source and the amount(s) received by the donor for this payment:
Name Amount Name Amount
3. Payment Information (Complete Sections 3.1 (a or b), 3.2, 3.3)
3.'l (a) Travel Payment
Location of Travel
Transportation Provider
% Rail g Air [3 Bus [] Auto [1 0ther
Check Applicable Boxes
Dates (month, day, year)
Name oF Lodging Facility
Lodging Expenses Meal Expenses Transporkation 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.
Food and service donation for all attendees of the Cupertino Swearing-in-Ceremony held on
12/1 4/23.
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
4. Verification
First Name Position/T itle Department/Division
(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 Public Document
This form is used t6 report certain payments received by state and local
(<overnment agencies. It include-s:
Part 1. Agency Idi
List the agency's n
Part 1. Agency Identification
List the agency's name and address and the name of an agency contact.
Mark the amendment box if changing any informat'on on a previously
filed form and include the date of the original filing.a payment for an official's travel expenses for the purpose of
facilitating the public's business in lieu of a payment using agency
funds; and
a payment that would otherwise be considered a gift or income
to the benefiting official, but is instead accepted on behalf of the
agency.
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 52,500 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 !,i2,500 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 filing officer for Statement of Economic Interests, Form
700, must receive the report. Within 30 days after the end of a
calendar quarter if aggregated reported payments total !,i2,500 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 emailed to form80l@fppc.ca.gov.
Statements may also be mailed to 1102 Q Street, Suite 3000,
Sacramento, CA 95811 or faxed to ('316) 322-3711.
Part 2. Donor Information
Disclose the name and address of the donor. If the donor is not an
individual, identify the business activity or nature and interests of the
entity.
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. Itemize 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 seminarin Washington o.c.
Section 3.3. Identify Officials
Travel Payments: The name ofthe position/title and departmentof
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.
Verification of non-travel payments must be signed by the agency head.
FPPC Form 801 (Jan/18)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)