HomeMy WebLinkAboutMichelle's Place - The Rita and Alfred Dann Foundation Behested Payment Report A Public Document Behested Payment Report
1. Elected Officer or CPUC Member(Last name,First name) Date Stamp a I ornia Q O 3
Naggar, Mike (Mayor) Form v
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, Legislative Director/City Clerk
Area Code/Phone Number E-mail (Optional) Date of Original Filing: 05-28-19
951-694-6444 randi.johl@temeculaca.gov (month,day,year)
2. Payor Information (For additional payors,include an attachment with the names and addresses)
The Rita and Alfred Dann Foundation
Name
30306 Carmenet Circle Murrieta CA 92563
Address City State Zip Code
3. Payee Information (For additional payees,include an attachment with the names and addresses.)
Michelle's Place Cancer Resource Center
Name
41669 Winchester Road, Suite 101 Temecula CA 92590
Address City State Zip Code
4. Payment Information (Complete all information)
Date of Payment: 05-17-19 Amount of Payment: (ln-KindFMV) $ 50,000
(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 ['Charitable
Describe the legislative, governmental, charitable purpose, or event: Donation to Michelle's Place to provide
expanded resources and services for all types of cancers in addition to breast cancer
5. Amendment Description and/or Comments
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 05-28-19 By 1( .
DATE � SIG ATURE OF. D OFFICER OR CPUC MEMBER
FPPC Form 803(January/2018)
FPPC Toll-Free Helpline: 866/ASK-FPPC(866/275-3772)