HomeMy WebLinkAboutMichelle's Place - Pechanga Community Fund Behested Payment Report A Public Document Behested Payment Report
1. Elected Officer or CPUC Member(Last name,First name) Date Stamp a i ornia 803
Naggar, Mike RECEIVED Form
Agency Name For Official Use Only
City of Temecula JUN 1 7 2019
Agency Street Address
41000 Main Street, Temecula 92590 CITY CLERKS DEPT.
Designated Contact Person (Name and title,if different) ❑ Amendment(See Part 5)
Randi Johl, City Clerk
Date of Original Filing: 6/17/19
Area Code/Phone Number E-mail (Optional) (month,day,year)
915-694-6444 randi.johl@temeculaca.gov
2. Payor Information (For additional payors,include an attachment with the names and addresses.)
Pechanga Community Fund
Name
PO Box 1477 Temecula CA 92593
Address City State Zip Code
3. Payee Information (For additional payees,include an attachment with the names and addresses.)
Michelle's Place Breast Cancer Resource Center
Name
27645 jefferson Avenue#177 Temecula CA 92590
Address City State Zip Code
4. Payment Information (Complete all information.)
Date of Payment: 5/21/19 Amount of Payment: (In-Kind FMV) $ 100,000
(month,day,year) (Round to whole dollars.)
Payment Type: ❑x Monetary Donation or ❑ In-Kind Goods or Services(Provide description below.)
Brief Description of In-Kind Payment:
Purpose:(Check one and provide description below.) ❑Legislative ❑Governmental ❑x Charitable
Describe the legislative, governmental, charitable purpose, or event: Donation to Michelle's Place for Expansion
of Services from Breast Cancer to All Types of Cancer Resource Center
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 _ 6/17/19 By
9 � �—+
DATE SIGNATURE OF ELECTED OFFICER OR CPUC MEMBER
FPPC Form 803(January/2018)
FPPC Toll-Free Helpline: 866/ASK-FPPC(866/275-3772)