November 3, 2020 Candidate Packet - Flipping Book Version

Behested Payment Report 1. Elected Officer or CPUC Member (Last name, First name) t t rt 1. lected fficer or e ber (Last name, First name)

A Public Document

li

t

Behested Payment Report Behested Payment Report

803 3

California Form alif r ia r

Date Stamp Date Stamp

Agency Name Agency Na e City of Oakmont Alvarez Manuel

For Official Use Only For Official Use Only

Agency Street Address Agency Street Address

Designated Contact Person (Name and title, if different) Designated Contact Person (Name and title, if different) 225 Presley Street, Oakmont, CA 95443

Amendment A end ent

(See Part 5) (See Part 5)

Madeline Richards

6/30/XX

Date of Original Filing: Date of Original Filing:

Area Code/Phone Number Area Code/Phone Nu ber

E-mail (Optional) E- ail (Optional)

(month, day, year) (month, day, year)

707-555-6868

mrichards@oakmontmail.com

Payor Information (For additional payors, include an attachment with the names and addresses.) 2. ayor Infor ation (For additional payors, include an attachment with the names and addresses.) 2.

Wildwood Insurance Company

Name Name

1022 Main Street

Oakmont

CA

Zip Code Zip Code 95443

Address Address

City City

State State

Payee Information (For additional payees, include an attachment with the names and addresses.) 3. ayee Infor ation (For additional payees, include an attachment with the names and addresses.) 3.

Boys and Girls Club of California

Name Name

555 10th Street

Sacramento

Zip Code Zip Code 95814

CA

Address Address

City City

State State

4. Payment Information 4. ay ent Infor ation

(Complete all information.) (Complete all information.)

5,000

6/24/XX

$ $

Date of Payment: Date of Payment: Payment Type: Pay ent Type:

Amount of Payment: (In-Kind FMV) Amount of Payment: (In-Kind FMV)

(Round to whole dollars.) (Round to whole dollars.)

(month, day, year) (month, day, year)

or or

Monetary Donation onetary onation

In-Kind Goods or Services In-Kind oods or Services

(Provide description below.) (Provide description below.)

Brief Description of In-Kind Payment: rief escription of In- ind Pay ent:

Purpose: (Check one and provide description below.) Purpose: (Check one and provide description below.)

Legislative Legislative

Governmental overn ental

Charitable haritable

Charitable fundraiser to support the Boys

Describe the legislative, governmental, charitable purpose, or event: Describe the legislative, governmental, charitable purpose, or event:

and Girls Club.

5. Amendment Description and/or Comments end ent escription or Comments e t escription or o ents .

6. Verification 6. erification

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. I certify, under penalty of perjury under the laws of the State of California, that to the best of y knowledge, the infor ation contained herein is true and co plete.

6/30/XX

[Signature Required]

Executed on Executed on

By By

DATE DATE

SIGNATURE OF ELECTED OFFICER OR CPUC MEMBER SIGNATURE OF ELECTED OFFICER OR CPUC MEMBER

Campaign Manual 2 June 2020 FPPC Form 803 (January/2018) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) FPPC Form 803 (December/09) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) FPPC For 803 (Dece ber/09) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)

Fair Political Practices Commission advice@fppc.ca.gov

Chapter 11. 5

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