HomeMy WebLinkAboutMichelle's Place - Pechanga Resort Casino Behested Payment Report A Public Document Behested Payment Report
1. Elected Officer or CPUC Member(Last name,First name) Date Stamp a I ornla 803
Mike Naggar, Mayor Form
Agency Name For Official Use Only
City of Temecula
Agency Street Address
41000 Main Street
Designated Contact Person (Name and title,if different) ❑ Amendment(See Part 5)
Randi Johl, City Clerk
Area Code/Phone Number E-mail (Optional) Date of Original Filing: May 14, 2019
(month,day,year)
951-694-6444 randi.johl@temeculaca.gov
2. Payor Information (For additional payors,include an attachment with the names and addresses)
Pechanga Resort Casino
Name
Post Office Box 9041 Temecula CA 92589
Address City State Zip Code
3. Payee Information (For additional payees,include an attachment with the names and addresses)
Michelle's Place
Name
27645 Jefferson Avenue, Suite 117 Temecula CA 92590
Address City State Zip Code
4. Payment Information (Complete all information)
Date of Payment: May 2, 2019 Amount of Payment: (ln-KindFMV) $ 125,000
(month,day,year) (Round to whole dollars)
Payment Type: ❑x Monetary Donation or ❑ In-Kind Goods or Services(Provide descnption below)
Brief Description of In-Kind Payment:
Purpose:(Check one and provide descnption below) ❑Legislative ❑Governmental ❑x Charitable
Describe the legislative, governmental, charitable purpose, or event:
Benefit and/or donation to Michelle's Place Breast Cancer Resource Center
5. Amendment Description and/or Comments
None
6. Verification
I certify, under penalty of perjury under the laws of the State of California,that to the best of my knowledge,the information contained
herein is true and complete
Executed on May 14, 2019 By ��`
DATE SIGNA RE OF ELECTED OFFICER OR CPUC MEMBER
FPPC Form 803(January/2018)
FPPC Toll-Free Helpline: 866/ASK-FPPC(866/275-3772)