Name of Outside Organization
(include address and description)C. Describe the public purpose made pursuant to the agency’s policy Identify one of the following:
California
Form
1. Agency Name
Designated Agency Contact (Name,Title)
Date Stamp
E-mail
Division, Department, or Region (If Applicable)
2. Function or Event Information
Comment:
FPPC Form 802 (4/12)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-7772)
802
(Month, Day, Year)
For Offi cial Use Only
Area Code/Phone Number
Date of Original Filing:
A Public Document
Amendment (Must provide explanation in Part 3.)
Was ticket distribution made at the behest
of agency offi cial?
Ticket(s)/Pass(es) provided by agency?
Event Description
Face Value of Each Ticket/Pass $
Date(s) / / / /
Name of Agency, Department or Unit
Number of
Ticket(s)/
Pass(es)
Number of
Ticket(s)/
Pass(es)
Number of
Ticket(s)/
Pass(es)
Offi cial’s Name (Last, First)
If no:
Describe the public purpose made pursuant to the agency’s policy Agency Report of:
Ceremonial Role Events and Ticket/Pass Distributions
3. Recipients
Yes No
Yes No
Name of Individual
(Last, First)
● Use Section A to identify the agency’s department or unit. ● Use Section B to identify an individual. ● Use Section C to identify an outside organization.
Does the agency have a ticket policy? Yes No
Provide Title/Explanation
A.
B.
If yes:
Name of Source
Ceremonial Role
Ceremonial Role
Other
Other
Income
Income
If checking “Ceremonial Role” or “Other” describe below:
If checking “Ceremonial Role” or “Other” describe below:
4. Verifi cation
I have read and understand FPPC Regulations 18944.1 and 18942. I have verifi ed that the distribution set forth above, is in accordance with the requirements.
Signature of Agency Head or Designee Print Name Title (Month, Day, Year)