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HomeMy Public PortalAbout11-10-15 - Holmes, Lula-DavisBehested Payment Report A Public Document 1. Elected Officer or CPUC Member (cast name, First name) Behested Payment Report Lula Davis -Holmes CITY CLER If Agency Name For Widal Use Only City of Carson 2015 NOV 10 PH 5: ill 701 E. Carson Street CITY OF CAflS N Designated Contact Person (Name and title, if different) ❑ Amendment (See Part 5) Area Code/Phone Number E-mail (Optional) Date of Original Filing: i f Iv (month, day, year) (310) 631-0504 ILHOLMES959@AOL.COM 2. Payor Information (For additional payors, include an attachment with the names and addresses) Waste Management Name 1970 E. 213th Street Carson CA 90745 Address City State Zlp Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Cultural Arts Foundation Name 603 B University Drive PMB 302 Carson CA 90746 Address city State Zip Code 4. Payment Information (completeallinforrnatlon.) Date of Payment: Sept. 17, 2015 {month, day, year) Amount of Payment: (!n•leind FMV) $ 7,500.00 (Round to whole dollars.) Payment Type: ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co -Sponsorship of two events $2500.00 for 2015 Juneteenth and $5000.00 for Jazz Festival for a total of $7500.00. 5. Amendment Description or Comments In 2015 CPUC Member Lula Davis -Holmes requested Waste Management monetary donations for the 2015 Juneteenth Celebration and the Jazz Festival. 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 // / By DATE FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Document This report is for use by elected officers and members of the California Public Utilities Commission (CPUC) to disclose payments made at their behest, principally for legislative, governmental, or charitable purposes. This form was prepared by the Fair Political Practices Commission (FPPC) and is available at www fppc.ca.gov. When to File File Form 803 within 30 days following the date on which the payment(s) meets or exceeds five thousand dollars ($5,000) in the aggregate from a single source in a calendar year. Once a single source has made a behested payment of $5,000 or more during the calendar year, subsequent payments of any amount from that source must be reported. Where to File State Officials: The official's state agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the state agency must forward a copy to the Fair Political Practices Commission (FPPC) 428 J Street, Suite 620, Sacramento, CA 95814. Fax; 916-322-0886 E-mail: Form8030fDDc_ca.00v Local Officials: The official's local agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the agency must forward a copy to the filing officer who receives the official's original campaign statements. General Information: Behested payments are payments made principally for legislative, governmental, or charitable purposes under Government Code Section 82015(b)(2)(B)(iii). These payments are not for personal or campaign purposes. Generally, a donation is made at the behest if it is requested, solicited, or suggested by the official, or otherwise made to a person in cooperation, consultation, coordination with, or at the consent of, the elected officer or CPUC member. This includes payments behested by the official or by his or her agent or employee on the official's behalf. Privacy Information Notice: Information requested by the FPPC is required by and used to administer and enforce the Political Reform Act. Failure to provide information may be a violation subject to administrative, criminal, or civil penalties. All reports and statements are public records available for inspection and reproduction. If you have any question regarding this notice, please contact General Counsel at 428 J Street, Suite 620, Sacramento, CA 95814 or (916) 322 -5660 - Instructions Part 1: Identification: Identify the official's name, agency, address, and contact information. Mark the amendment box if changing information on a previously filed Form 803 and include the date of the original filing. Part 2: Payor Information: Disclose the name and address of the person making the payment. A business address is acceptable. Part 3: Payee Information: Identify the name and address of the person receiving the payment, if applicable. A business address is acceptable. Part 4: Payment Information: Disclose the payment date and amount using the fair market value (FMV) for donated in-kind goods or services- Check one box to identify the type of payment and provide a description if the payment is an in-kind good or service. Check one box to identify the purpose and provide a description. Use Part 5 for additional or clarifying information. Part 5: Amendment Description or Comments: Complete this section if amending a previously filed Form 803 or to provide additional information. Part 6: Verification: Date and sign the form under penalty of perjury. Example On April 24, 2010, at CPUC Member Tully's request, the ABC Corporation made a monetary donation of $5,000 to the Boys and Girls Club. 2. Payorinfamutionjra.ad*xwryw.dr.�:r.�ma;:ma.af ABL GrcrAKM 12344haAve. sacrament CA 95814 whn cq no 'a cad 3. Payee Information wMJT rWreS.ae.asr$Wr t The Boys and cuts W km 5878 Bravo SW smamento CA VAIA cor sm yore* 4. Payment Information rex.rw.�yr Date of Payment Apa124, 2018 Amount of Payment: 1b oudFlnt $ 5 000 f�A ap)w fab. ddn} Pwsent ppe. WMonstaryDonation or ❑h4GndGoods orSumesfnaa.m.ovaebc 1 901 I1esulptfon of h -KhW Payment. PurW­ao,, r- f.­P0ara,f ❑ Legwam ❑Goverm "I ®charifaw Oesaft the legKbOve governmental, chalttahle purpose or event f]ana6an t dzitdrert's mrmna> ty senna FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 8661ASK-FPPC (8661275-3772) Behested Payment Report A Public Document BehesledPayment Report 1. Elected Officer or CPUC Member (Last name, First name) Lula Davis -Holmes City of Carson 701 E. Carson Street Area Code/Phone Number E-mail (Optional) (310) 631-0504 ILHOLMES959@AOL.COM CITY CLE 2015 NOV 10 PM CITY OF CAF For Official Use Only 42 ❑ Amendment (see Part 5) �j] Date of Original Filing: - -I — (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses) Waste Management Name 1970 E. 213th Street Carson CA 90745 Address City State Zlp Code 3. Payee Information (For additional payees, include an attachment with the names and addresses) Carson Citizen Cultural Arts Foundation Name 603 B University Drive PMB 302 Carson CA 90746 Address city State Zip Code 4. Payment Information (complete all information) Date of Payment: Sept. 8, 2014 Amount of Payment: (in-tGnd FMv) $ 8,500.00 (month, day, year) (Round to whole dollars.) Payment Type: ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co-sponsorship of the following events: 2014 Juneteenth, 2014 Jazz Festival and 2014 Turkey Give Away. 5. Amendment Description or Comments In 2014 CPUC Member Lula Davis -Holmes requested Waste Manager make a monetary donation totaling $8,500.00 for the following events and amounts, $2,500 for the Juneteenth, $5,000 for the Jazz Festival and $1,000 for the Turkey give Away. 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. �i %� 9 Z- Executed on By DATE SIGNATURE OF ELECTED OFFICER OR C FPPC Form 843 (December/0% FPPC Toll -Free Helpline: 866tASK-FPPC (8661275-3772) Behested Payment Report A Public Document This report is for use by elected officers and members of the California Public Utilities Commission (CPUC) to disclose payments made at their behest, principally for legislative, governmental, or charitable purposes. This form was prepared by the Fair Political Practices Commission (FPPC) and is available at www.fppc.ca.gov. When to File File Form 803 within 30 days following the date on which the payment(s) meets or exceeds five thousand dollars ($5,000) in the aggregate from a single source in a calendar year. Once a single source has made a behested payment of $5,000 or more during the calendar year, subsequent payments of any amount from that source must be reported. Where to File State Officials: The official's state agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the state agency must forward a copy to the Fair Political Practices Commission (FPPC) 428 J Street, Suite 620, Sacramento, CA 95814. Fax: 916-322-0886 E-mail: Form803@fooc.ca.gov Local Officials: The official's local agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the agency must forward a copy to the filing officer who receives the official's original campaign statements. General Information: Behested payments are payments made principally for legislative, governmental, or charitable purposes under Government Code Section 82015(b)(2)(B)(iii). These payments are not for personal or campaign purposes. Generally, a donation is made at the behest if it is requested, solicited, or suggested by the official, or otherwise made to a person in cooperation, consultation, coordination with, or at the consent of, the elected officer or CPUC member. This includes payments behested by the official or by his or her agent or employee on the official's behalf. Privacy Information Notice: Information requested by the FPPC is required by and used to administer and enforce the Political Reform Act. Failure to provide information may be a violation subject to administrative, criminal, or civil penalties_ All reports and statements are public records available for inspection and reproduction. If you have any question regarding this notice, please contact General Counsel at 428 J Street, Shite 620, Sacramento, CA 95814 or (916) 322-5660. Instructions Part 1: Identification: Identify the official's name, agency, address, and contact information. Mark the amendment box if changing information on a previously filed Form 803 and include the date of the original filing. Part 2: Payor Information: Disclose the name and address of the person making the payment_ A business address is acceptable. Part 3: Payee Information: Identify the name and address of the person receiving the payment, if applicable. A business address is acceptable. Part 4: Payment Information: Disclose the payment date and amount using the fair market value (FMV) for donated in-kind goods or services. Check one box to identify the type of payment and provide a description if the payment is an in-kind good or service. Check one box to identify the purpose and provide a description. Use Part 5 for additional or clarifying information. Part 5: Amendment Description or Comments: Complete this section if amending a previously fried Form 803 or to provide additional information. Part 6: Verification: Date and sign the form under penalty of perjury. Example On April 24, 2010, at CPUC Member Tully's request, the ABC Corporation made a monetary donation of $5,000 to the Boys and Girls Club. 2. Payor Information (ra.2xh9alp ron =%.t a7 itatlana tra e e w les ae.mr es] 1234 Atha Ave_ Seuememp CA '4 Amex 3. Payee Imfarmation ;�a.edarwrees. mdah an rlradmne+an eR lnnea ria.shesarll The Bars and GOs Milo am 5518 Brava 13W., Secremerta CA 560 14 Agana ur SIM hP m 4, Payment Information Gate oI Paymmt: Ap,424, 2010 Atmountof Paymenl: • c.1i•an9 $ 5.000 !^tet ar poo {rmwe.lw.a.a Payment Type: ® Monetary motion or ❑ WKKind Goods or Services �&_w BHN Gesodpllon of Ar to Payrnem: Purpose:rcbam.dpaaa,rornsl6.. {3Leplaty ❑Gevemwtsl ❑ehanlahle Gesaft the "Isladve, governmental, charmle purpose, Of event: Donation to chl&V4 =Mwity service «ganoWn. FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Document 1. Elected Officer or CPUC Member (Last name, First name) Lula Davis -Holmes City of Carson 701 E. Carson Street, Carson, CA 90745 Designated Contact Person (Name and title, if different) Area Code/Phone Number i E-mail (Optional) ITY CLERK 2�5 Nov 10 pH 5: Behested Payment Report For Official Use Only ❑ Amendment (see Part s) Date of Original Filing: 1 _q_1 (month, day, year) (310) 631-0504 lIholmes959@aol.com I 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Waste Management Name 1970 E. 213th Street Address Carson C.ty 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizens Cultural Arts Foundation Name CA 90810 State Zip Code 603 B University Drive PMB 302 Carson CA 90746 Address City State Zip Code 4. Payment Information (complete all inrormallon) Date of Payment: 10/14/13 Amount of Payment: iln-KindFMV) $ 5,000.00 (month, day, year) (Round to whole dollars.) Payment Type: ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co-sponsorship of the 2014 Juneteenth Celebration and the 2014 Jazz Festival. 5. Amendment Description or Comments in 2014 CPUC Member Lula Davis -Holmes requested Waste Management make a monetary donation in the amount of $5,000.00 for the 2014 Juneteenth Celebration and the 2014 Jazz Festival. Each event was given $2,500.00. 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 DATE 95 51UNATURE OF FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Document This report is for use by elected officers and members of the California Public Utilities Commission (CPUC) to disclose payments made at their behest, principally for legislative, governmental, or charitable purposes. This form was prepared by the Fair Political Practices Commission (FPPC) and is available at www.fppc.ca.gou When to File File Form 803 within 30 days following the date on which the payment(s) meets or exceeds five thousand dollars ($5,000) in the aggregate from a single source in a calendar year. Once a single source has made a behested payment of $5,000 or more during the calendar year, subsequent payments of any amount from that source must be reported. Where to File State Officials: The official's state agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the state agency must forward a copy to the Fair Political Practices Commission (FPPC) 428 J Street, Suite 620, Sacramento, CA 95814, Fax: 916-322-0886 E-mail: Form803@fooc,ca.gov Local Officials: The official's local agency must receive Form 803 within 30 days of the date the behested payment is made_ Within 30 days after receipt of the report, the agency must forward a copy to the filing officer who receives the official's original campaign statements. General Information: Behested payments are payments made principally for legislative, governmental, or charitable purposes under Government Code Section 82015(b)(2)(13)(iii). These payments are not for personal or campaign purposes. Generally, a donation is made at the behest if it is requested, solicited, or suggested by the official, or otherwise made to a person in cooperation, consultation, coordination with, or at the consent of, the elected officer or CPUC member. This includes payments behested by the official or by his or her agent or employee on the official's behalf. Privacy Information Notice: Information requested by the FPPC is required by and used to administer and enforce the Political Reform Act. Failure to provide information may be a violation subject to administrative, criminal, or civil penalties. All reports and statements are public records available for inspection and reproduction. If you have any question regarding this notice, please contact General Counsel at 428 J Street, Suite 620, Sacramento, CA 95814 or (916) 322-5660. Instructions Part 1: Identification: Identify the official's name, agency, address, and contact information. Mark the amendment box if changing information on a previously filed Form 803 and include the date of the original filing_ Part 2: Payor Information: Disclose the name and address of the person making the payment. A business address is acceptable. Part 3: Payee Information: Identify the name and address of the person receiving the payment, if applicable. A business address is acceptable. Part 4., Payment Information: Disclose the payment date and amount using the fair market value (FMV) for donated in-kind goods or services. Check one box to identify the type of payment and provide a description if the payment is an in-kind good or service. Check one box to identify the purpose and provide a description. Use Part 5 for additional or clarifying information. Part 5: Amendment Description or Comments: Complete this section if amending a previously filed Form 803 or to provide additional information. Part 6: Verification: Date and sign the form under penalty of perjury. Example On April 24, 2010, at CPUC Member Tully's request, the ABC Corporation made a monetary donation of $5,000 to the Boys and Girls Club. ABC 1234AOoAve. Sommento CA VW 14 A&M cti so* +.. m 3. Payee Information rFamw*pym-+a*myuadmvl-no*nx*'n-ten':{'. The Boys and We alb him SUB BrowElvd., Sammeyc CA � Ur sto r� . K* -p *4d M. Dale of payment � 2 .2010 Amwnt of Payment: pworw S 5 000b -ti.. � PaymMtim! ®6lanetuyDonation or ❑b, -Kind Goods orSwxesfi-*ero.1 Bdef Descdp m or Mind Payment: "se: (0 . , , " fie.; ❑Eepplah* 7Govenmvw ©chantIN Describe the Ieglslative, governmental charitable purpose. or event Donation to dm*Ws wry sernn vwawr, FPPC Form 803 (December109) FPPC Toll -Free Helpline: 866/ASK-FPPC(8661275-3772) Behested Payment Repoli A Public Document 9. Elected Officer or CPUC Member (Last name, First name) Lula Davis -Holmes 6?il�t`LE Agency Name City of Carson 2015 HOY 10 PM 701 E. Carson Street Area Code/Phone Number (310) 631-0504 (Name and title, if different) Email (Optional) COM CITY OF ❑ Amendment (see Pad 5) Behested Payment Report 42 For Official Use Only Date of Original Filing: //.- q (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses) Tesoro Refinery Name 2350 E. 223rd St Carson CA 90810 Address City State Zlp Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Cultural Arts Foundation Name 603 B. University Drive PMB 302 Carson CA 90746 Address City State Zip Code 4. Payment Information (complete all information.) Date of Payment: July 7, 2015 Amount of Payment: (ln-ta aFm,4 $ 10,000.00 (month, day, year) (Round to whole dollars.) Payment Type: ® Monetary Donation or ❑ In -Kind Goods or Services (provide desadptlonbelow.) Brief Description of In -Kind Payment: Purpose: (Check one and provide description below.) ❑ Legislative ❑ Governmental ® Charitable Describe the legislative, governmental, charitable purpose, or event: Celebration Co-sponsorship of 2015 Juneteenth 5. Amendment Description or Comments In 2015 CPUC Member Lula Davis -Holmes requested a monetary donation from Tesoro for the 2015 Juneteenth Celebration. The organization submitted a grant application and was awarded $10,000.00. 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 //_ 0A1T FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 8661ASK-FPPC (8661275-3772) Behested Payment Report A Public Document This report is for use by elected officers and members of the California Public Utilities Commission (CPUC) to disclose payments made at their behest, principaily for legislative, governmental, or charitable purposes. This form was prepared by the Fair Political Practices Commission (FPPC) and is available at www.fppc.ca.gov. When to File File Form 803 within 30 days following the date on which the payment(s) meets or exceeds five thousand dollars ($5,000) in the aggregate from a single source in a calendar year. Once a single source has made a behested payment of $5,000 or more during the calendar year, subsequent payments of any amount from that source must be reported. Where to File State Officials: The official's state agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the state agency must forward a copy to the Fair Political Practices Commission (FPPC) 428 J Street, Suite 620, Sacramento, CA 95814. Fax: 916-322-0886 E-mail: Form8030fDoc.ca.00v Local Officials: The official's local agency must receive Form 803 within 30 days of the dale the behested payment is made. Within 30 days after receipt of the report, the agency must forward a copy to the filing officer who receives the official's original campaign statements _ General Information: Behested payments are payments made principally for legislative, governmental, or charitable purposes under Government Code Section 82015(b)(2)(13)(iii). These payments are not for personal or campaign purposes. Generally, a donation is made at the behest if it is requested, solicited, or suggested by the official, or otherwise made to a person in cooperation, consultation, coordination with, or at the consent of, the elected officer or CPUC member. This includes payments behested by the official or by his or her agent or employee on the official's behalf. Privacy Information Notice: Information requested by the FPPC is required by and used to administer and enforce the Political Reform Act. Failure to provide information may be a violation subject to administrative, criminal, or civil penalties. All reports and statements are public records available for inspection and reproduction. If you have any question regarding this notice, please contact General Counsel at 428 J Street, Suite 620, Sacramento, CA 95814 or (916) 3225660_ Instructions Part 1; Identification: Identify the official's name, agency, address, and contact information. Mark the amendment box if changing information on a previously filed Form 803 and include the date of the original filing. Part 2: Payor Information: Disclose the name and address of the person making the payment. A business address is acceptable. Part 3: Payee Information: Identify the name and address of the person receiving the payment, if applicable. A business address is acceptable. Part 4: Payment Information: Disclose the payment date and amount using the fair market value (FMV) for donated in-kind goods or services. Check one box to identify the type of payment and provide a description if the payment is an in-kind good or service. Check one box to identify the purpose and provide a description. Use Part 5 for additional or clarifying information. Part 5: Amendment Description or Comments: Complete this section if amending a previously filed Form 803 or to provide additional information. Part 6: Verification: Date and sign the form under penalty of perjury. Example On April 24, 2010, at CPUC Member Tully's request, the ABC Corporation made a monetary donation of $5,000 to the Boys and Girls Club. 2 PayorInformationlraetw piron.ckdrauvsarMemrmvsame:rd+aerxsl ABC CwXfnm 1234AOaAve.. sammerno CA 95814 nm.r Cq SAa to C4M* 3. Payee lnfomration iFar,mmurpures. ra LlenS�dmr errAasnnnaM �l4exus7 The Boyo and Geo Club R 567$ Bravo Blvd, CA 95813 ft� u sa zocva< 4. Payment Information DaleofPaymern: APO2b.2016 Amaunto1Payment,rbam-K155000 P -A wr rw (&.W bah* dA" ) Payment 1ppe: ® Monetary Dmation or ❑ In4W Goo&or Sermsln­wa, ew.l Brie) DeWptlao of M4W Payment: Purpose: 0—wo-w*-0obwJ ❑Legislative ❑Go"=*nal 11Chubblo Deetrlbe the leglslanre, govemmeWl, charaeme pwpose, or event Donation to dsldren's mmraniry service FPPC Form 803 (December109) FPPC Toll -Free Helpline: 866/ASK-FPPC (86612753772) Behested Payment Report A Public Document 1. Elected Officer or CPUC Member (Last name, First name) ai iPVED Lula ILIw.-... Halmes CITY CLERK A----.. 111 City of Carson 701 E. Carson Street Area Code/Phone Dumber (310) 631-0504 (Name and title, if different) E-qnali (Optional) LHOLMES959@AOL.COM 15 NOV 10 PN 5: ❑ Amendment (See Part 5) Behested Payment Report For Oficial Un Oniy Date of Original Filing: 1/ f 16 (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses) Tesoro Refinery Name 2350 E. 223rd Street Carson CA 90810 Address City State Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Cultural Arts Foundation Name 603 B University Drive PMB 302 Carson CA 90746 Address City State Zip Code 4. Payment Information (complete allinformation) Date of Payment: June 26, 2014 Amount of Payment: (1mKfnd FMt9 $ 5000.00 (month, day, year) (Round to whole dollars) Payment Type: ® Monetary Donation or ❑ In -Kind Goods or Services (provide description below) Brief Description of In -Kind Payment: Purpose: (Check one end provide description below.) ❑ Legislative ❑ Governmental ® Charitable Describe the legislative, governmental, charitable purpose, or event: Juneteenth Celebration in the amount of $5,000.00. Co -Sponsorship of the 2014 5. Amendment Description or Comments In 2014 CPUC Member Lula Davis -Holmes requested Tesoro make a monetary donation to the CCCAF for the 2014 Juneteenth Celebration 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 DATE By FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Document This report is for use by elected officers and members of the California Public Utilities Commission (CPUC) to disclose payments made at their behest, principally for legislative, governmental, or charitable purposes. This form was prepared by the Fair Political Practices Commission (FPPC) and is available at www.fppc.ca.gov. When to File File Form 803 within 30 days following the date on which the payment{s) meets or exceeds five thousand dollars ($5,000) in the aggregate from a single source in a calendar year. Once a single source has made a behested payment of $5,000 or more during the calendar year, subsequent payments of any amount from that source must be reported. Where to File .tate..Officials: The official's state agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the state agency must forward a copy to the Fair Political Practices Commission (FPPC) 428 J Street, Suite 620, Sacramento, CA 95814. Fax: 916-322-0886 E-mail: Form803@fgpc-ca.gov Local Officials: The official's local agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the agency must forward a copy to the filing officer who receives the official's original campaign statements_ General Information: Behested payments are payments made principally for legislative, governmental, or charitable purposes under Government Code Section 82015(b)(2)(B)(iii). These payments are not for personal or campaign purposes_ Generally, a donation is made at the behest if it is requested, solicited, or suggested by the official, or otherwise made to a person in cooperation, consultation. coordination with, or at the consent of, the elected officer or CPUC member. This includes payments Behested by the official or by his or her agent or employee on the official's behalf. Privacy Information Notice: Information requested by the FPPC is required by and used to administer and enforce the Political Reform Act. Faiture to provide information may be a violation subject to administrative, criminal, or civil penalties. All reports and statements are public records available for inspection and reproduction. If you have any question regarding this notice, please contact General Counsel at 428 J Street, Suite 620, Sacramento, CA 95814 or (9 16) 3225660. Instructions Part 1: Identification: Identify the official's name, agency, address, and contact information. Mark the amendment L_ if changing information on a previously filed Form 803 and include the date of the original fling. Part 2: Payor Information: Disclose the name and address of the person making the payment- A business address is acceptable. Part 3: Payee Information: Identify the name and address of the person receiving the payment, if applicable. A business address is acceptable. Part 4: Payment Information: Disclose the payment date and amount using the fair market value (FMV) for donated in-kind goods or services. Check one box to identify the type of payment and provide a description if the payment is an in-kind good or service. Check one box to identify the purpose and provide a description. Use Part 5 for additional or clarifying information. Part 5: Amendment Description or Comments: Complete this section if amending a previously filed Form 803 or to provide additional information. Part 6: Verification: Date and sign the form under penalty of perjury. Example On April 24, 2010, at CPUC Member Tully's request, the ABC Corporation made a monetary donation of $5,000 to the Boys and Girls Club. 2. Payor Information Sn 0ft&W paq: rrldr an a ruhrcnt.a ee mrcs ad adtrxs m c corparat on 1234AIphaAve. Saaemenpp CA 95814 AMM rry nor is C.6 3. Payne Information rFo aAk ow W1K+. +.Adr a� al d.rd rcp !Ar �re7 end at�riuA f The Em and Gets Ch6 5678 Brave OW *ralNbMrAm". Seeremerda CA 95814 DateWPaynrenL ApPcfdk dn AmoantolPaymeM:••c.arn155. we"du�J Payment Type: E)Mmetary Donation or 0 Np Geode or Servkaspi.ra_.omdc. $ref description of br•11ind Payment Pufpose:ltA.as ,d..a.aa.. bk.r OLeOAs ve ❑Govemmental ®chffa* Dewibe the legislative. gmernmenW. dlanable purpose. of eVetrL Dana5" oh'ldreds Corm FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 8661A5K-FPPC (8661275-3772) Behested Payment Report A Public Document 1. Elected Officer or CPUC Member (Last name, First name) "' Lula Davis -Holmes CITY CLERK Agency Name City of Carson. „---- ZO 5 Nov 10 pH 5: 51 701 E. Carson Street, Carson, CA 90745 Area Code/Phone Number (310) 631-0504 (Name and title, if different) E-mail {Optional) Iholmes959@aol.com OF Behested Payment Report For Official Use Only ❑ Amendment (see Pad 5) Date of Original Filing: (month, day, year) 2. Payor Information (Foradditional payors, include an attachment with the names and addresses) BP Name 2350 E. 223rd Street Carson CA 90810 Address City state Zlp Code 3. Payee Information (For additional payees, include an attachment with the names and addresses) Carson Citizens Cultural Arts Foundation Name 603 B University Drive PMB 302 Carson CA 90746 Address city state Zip Code 4. Payment Information (complete allinlormation.) Date of Payment: 10/14/13 Amount of Payment: (ln-Klnd FMV) $ 5,000.00 (month, day, year) (Round to whole dollars.) Payment Type: ® Monetary Donation or ❑ In -Kind Goods or Services (Provide desorption below.) Brief Description of In -Kind Payment: Purpose: (Check one and provide desanplion below.) ❑ Legislative ❑ Governmental ® Charitable Describe the legislative, governmental, charitable purpose, or event: Celebration in the amount of $5,000.00 5. Amendment Description or Comments Co-sponsorship of the 2015 Juneteenth In 2013 CPUC Member Lula Davis -Holmes requested BP make a monetary donation in the amount of $5,000.00 for the 2014 Juneteenth Celebration. 6. Verification I certify, under penalty of perjury under the laws of the Slate of California, that to the best of my knowledge, the information contained herein is true and complete. Executed on By .19, a, � / �/� DATE SIGNATURE OF ELECTED OFFICER OR CPUC MEMBER FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Document This report is for use by elected officers and members of the California Public Utilities Commission (CPUC) to disclose payments made at their behest, principally for legislative, governmental, or charitable purposes. This form was prepared by the Fair Political Practices Commission (FPPC) and is available at www.fppc.ca.gov. When to File File Form 803 within 30 days following the date on which the payment(s) meets or exceeds five thousand dollars ($5,000) in the aggregate from a single source in a calendar year. Once a single source has made a behested payment of $5,000 or more: during the calendar year, subsequent payments of any amount from that source must be reported. Where to File State Officials: The official's state agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the state agency must forward a copy to the Fair Political Practices Commission (FPPC) 428 J Street, Suite 620, Sacramento, CA 95814. Fax: 916-322-0886 E -malt: v Local Officials: The official's local agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the agency must forward a copy to the fling officer who receives the official's original campaign statements. General Information: Behested payments are payments made principal)y for legislative, governmental, or charitable purposes under Government Code Section 82015(b)(2)(13)(iii). These payments are not for personal or campaign purposes. Generally, a donation is made at the behest if it is requested, solicited, or suggested by the official, or otherwise made to a person in cooperation, consultation, coordination with, or at the consent of, the elected officer or CPUC member. This includes payments behested by the official or by his or her agent or employee on the official's behalf. Privacy Information Notice: Information requested by the FPPC is required by and used to administer and enforce the Political Reform Act. Failure to provide information may be a violation subject to administrative, criminal, or civil penalties. All reports and statements are public records available for inspection and reproduction. If you have any question regarding this notice, please contact General Counsel at 428 J Street, Suite 620, Sacramento, CA 95814 or (916) 322»5660_ Instructions Part 1: Identification: Identify the official's name, agency, address, and contact information. Mark the amendment box if changing information on a previously filed Form 803 and include the date of the original filing. Part 2: Payor Information: Disclose the name and address of the person making the payment. A business address is acceptable. Part 3: Payee Information: Identify the name and address of the person receiving the payment, if applicable. A business address is acceptable. Part 4: Payment Information: Disclose the payment date and amount using the fair market value (FMV) for donated in-kind goods or services. Check one box to identify the type of payment and provide a description if the payment is an in-kind good or service. Check one box to identify the purpose and provide a description. Use Part 5 for additional or clarifying information. Part 5: Amendment Description or Comments: Complete this section if amending a previously filed Form 803 or to provide additional information. Part 6: Verification: Date and sign the form under penalty of perjury. Example On April 24, 2010, at CPUC Member Tully's request, the ABC Corporation made a monetary donation of $5,000 to the Boys and Girls Club. aer.�wwws r�ano~�mK,urindKrr.rcsma��1 ABC Carpaaban 123 4hake.. seaamerdo CA 95314 Mfea CA sm 10 teal 3. Payee Information ,rn,aamdw,m wide a �lgdra� em esr �rt rs r d rk5reaesl The eon and Gds Cwn 5fi ormf3w Saaameerm CA 9F"'4 4. Payment Information �ea�xerre,ewm. DateofPaymem. ApM24.201D Amount ofPaymenl:e.Ks) w1S5,00D P-e,WYW pbdkwr w_i Paymeft1w. EJMonetryDmdw or ❑ In -Kind GoodsofSermespw,*_eo.w. ffrkl Desatptfon of M40W Pnymem: ftme:lch. mxaar� ❑f.egswn ❑Govemmentai 0ChWW* DlStilaetlk legYslative, govemmnnal, cnarttante purpose oreYerlC �'°' to chldrensurm FPPC Form 603 (December109) FPPC Toll -Free Helpline: 866/ASK-FPPC (6661275-3772) Behested Payment Report A Public Document 1. Elected Officer or CPUC Member (cast name, First name) ri i—dr46 EE' Davis -Holmes CITY CLER City of Carson Agency Street j 701 E. Carson Street Area Code/Phone Number (310) 631-0504 (Name and title, if different) E-mail (optional) ES959@AOL.COM 15 Nov 10 PH 5: 5 OF Ballasted Payment Report For Official Use Only ❑ Amendment (See Part 5) Date of Original Filing: 11_q (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses) BP Name 2350 E. 223rd Street Carson CA 90810 Address City state Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses) Carson Citizen Cultural Arts Foundation Name 603 B. University Drive PM8 302 Carson CA 90746 Address City state Zip Code 4. Payment Information (Complete alllntarmatlon) Date of Payment: 09112 Amount of Payment: (in-ivndFMv) $ 5,000.00 (month, day, year) (Round to whole dollars.) Payment Type: ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Celebration in the amount of $5,000.00 Co-sponsorship of the 2012 Juneteenth S. Amendment Description or Comments In 2012 CPUC Member Lula Davis -Holmes requested BP make a monetary donation in the amount of $5,000.00 for the 2012 Juneteenth Celebration. 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 //— / /,5-- By WE FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 8661ASK-FPPc (8661275-3772) Behested Payment Report A Public Document This report is for use by elected officers and members of the California Public Utilities Commission (CPUC) to disclose payments made at their behest, principally for legislative, governmental, or charitable purposes. This form was prepared by the Fair Political Practices Commission (FPPC) and is available at w`~1 wfppc.ca.gov. When to File File Form 803 within 30 days following the date on which the payment(s) meets or exceeds five thousand dollars ($5,000) in the aggregate from a single source in a calendar year. Once a single source has made a behested payment of $5,000 or more during the calendar year, subsequent payments of any amount from that source must be reported. Where to File State Officials: The official's state agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the state agency must forward a copy to the Fair Political Practices Commission (FPPC) 428 J Street, Suite 620, Sacramento, CA 95814. Fax: 916-322-0886 E-mail: Form803(afppc.ca.aov LoCyl Of idnis: The official's local agency must receive Form 803 within 30 days of the date the behested payment is made. Within 30 days after receipt of the report, the agency must forward a copy to the filing officer who receives the official's original campaign statements. General Information: Behested payments are payments made principally for legislative, governmental, or charitable purposes under Government Code Section 82015(b)(2)(13)(iii). These payments are not for personal or campaign purposes. Generally, a donation is made at the behest if it is requested, solicited, or suggested by the official, or otherwise made to a person in cooperation, consultation, coordination with, or at the consent of, the elected officer or CPUC member. This includes payments behested by the official or by his or her agent or employee on the official's behalf. Privacy Information Notice: Information requested by the FPPC is required by and used to administer and enforce the Political Reform Act. Failure to provide information may be a violation subject to administrative, criminal, or civil penalties. All reports and statements are public records available for inspection and reproduction. If you have any question regarding this notice, please contact General Counsel at 428 J Street, Suite 620, Sacramento, CA 95814 or (916) 322-5660. Instructions Part 1: Identification: Identify the official's name, agency, address, and contact information. Mark the amendment box if changing information on a previously filed Form 803 and include the date of the original €icing. Part 2: Payor Information: Disclose the name and address of the person making the payment. A business address is acceptable. Part 3: Payee Information: Identify the name and address of the person receiving the payment, if applicable. A business address is acceptable. Part 4: Payment Information: Disclose the payment date and amount using the fair market value (FMV) for donated in-kind goods or services. Check one box to identify the type of payment and provide a description if the payment is an in-kind good or service. Check one box to identify the purpose and provide a description. Use Part 5 for additional or clarifying information - Part 5: Amendment Description or Comments: Complete this section if amending a previously filed Form 803 or to provide additional information. Part 6: Verification: Date and sign the form under penalty of perjury. Example On April 24, 2010, at CPUC Member Tully's request, the ABC Corporation made a monetary donation of $5,000 to the Boys and Girls Club, (tw�eEoralp� rrhtr•aa eC,chnad�Isrom7 addties'+n1 ABC Zapyn r 1234A1phaAve, Saawa to CA 95814 AMM eq sa ianbr IPayee tplonnationirarsz wxrm�err�d,�rr.neKmm�niaa4rsttrp The Boys and Gila C4fi N" 5518 earm 8W., Seuammo CA 95814 w.y G s a to C.& 4. Payment Information rco,p eM,ar,,� i Date of Payment: Apm124, 2018 Amount at Payment: o wtsm $ 5 080 r -9k ar rw f�,re.mrmrnr Payrn nl Type: El Moneuvy Danatim or ❑ InA d Goods orSenticesy erlef Oesalyiar oT Indtlnd Paymem: Purpose:OLegnl M ❑Governmental ®eharitah Demlhe tle Ieglstaft governmental, cdarMle purpose, or event: Donation to children's eonmrauly service ef2=11an FPPC Form 803 (December/09) FPPC Tall -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Docu 1. Elected Officer or CPUC Member (Lastname, First name) Lula Davis Holmes City of Carson 701 E Carson STREET Area Code/Phone Number K711I:N31Hb11112 (Name and title, if different) E-mail (optional) LMES959@AOLCOM Behested Payment Report TY K For Official Use Only 2015 00Y 10 PM 3: 38 OF CARSON ❑ Amendment (See Part 5) Date of Original Filing: 11-9-2015 (month, day. year) 2. Payor Information (For additional payors, include an attachment with the names and addresses) BP Name 2350 E. 223rd St Carson Ca 90810 Address City Stale Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Cultud Arts Foundation Name 603 B University Drive PMB 302 Carsn Ca 90746 Address City State Zip Code 4. Payment Information (Complete all information.) Date of Payment: Sept 2012 Amount of Payment: (In-wndFM17 $ $5000.00 (month, day, year) (Round to whole dollars.) Payment Type: ® Monetary Donation or ❑ In -Kind Goods or Services (Pmvidedescription berow.) Brief Description of In -Kind Payment: Purpose: (Check one and provide description below.) ❑ Legislative ❑ Governmental ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co Sponsorship of following Events Juneteenth Sept 2012 for $5,000, 5. Amendment Description or Comments IN 2012 CPUC Member Lula Davis Holmes requeted that BP make a monetary donaton totaling $5,000 for the Following events. Juneteenth Celebration $5,000. 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 November 9, 2015 DATE FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Document 1. Elected Officer or CPUC Member(Lastname, First name) HL p` t Lula Davis Holmes !TY CLERK City of Carson rens 701 E Carson STREET Area Code/Phone Number 310 6310504 (Name and title, if different) E-mail (Optional) LHOLMES959@AOL.COM NOV 10 PM 3: 38 ❑ Amendment (See Pan 5) Behested Payment Report For Official Use Only Date of Original Filing: 11-9-2015 (month, day year) 2. Payor Information (For additional payors, include an attachment with the names and addresses.) BP Name 2350 E. 223rd St Carson Ca 90810 Address City Stale Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses) Carson Citizen Cultud Arts Foundation Name 603 B University Drive PMB 302 Carsn City 4. Payment Information (complete all information.) Ca 90746 Slate Zip Code Date of Payment: 5/15/2013 Amount of Payment: (In -Kind FM%0 $ $5000.00 (month, day, year) (Round to whole dollars) Payment Type: ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co Sponsorship of following Events Juneteenth May 15, 2013 for $5,000, S. Amendment Description or Comments IN 2013 CPUC Member Lula Davis Holmes requeted that BP make a monetary donaton totaling $5,000 for the Following events. Juneteenth Celebration $5,000. 6. Verification I certify, under penalty of perjury under the laws of the Slate of California, that to the best of my knowledge, the information contained herein is true and complete. Executed on November 9, 2015 DATE FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (866127rr3772) Behested Payment Report A Public Docu 1. Elected Officer or CPUC Member(Lastname, First name) Lula Davis Holmes 959 E. Gladwick Street Carson, California 90746 (Name and title, if different) Area Code/Phone Number E-mail (Optional) 310 631-0504 1 Iholmes9590)v LC;EiVED Date MOV 25 PM 2: 4 OF CARSON ❑ Amendment (see Parts) Behested payment Report For Official Use Only Date of Original Filing: Nov. 25, 2015 (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses) CVS Corporation Name 1 CVS Drive Woonsocket RI 02895 Address City state Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses ) Carson Citizen Cultural Arts Foundation Name 603 B University Drive PMB 302 Carson CA 90746 Address city state Zip Code 4. Payment information (completeallinformahon.) Date of Payment: Payment Type: 10/26/2015 (monlh, day, year) Amount of Payment: (!n -Kind FMV) $ 5,000.00 (Round to whole dallars ) ® Monetary Donation or ❑ In -Kind Goods or Services (Provide description below) Brief Description of In -Kind Payment: Purpose: (Check one and provide descnphon below) ❑ Legislative ❑ Governmental ® Charitable Describe the legislative, governmental, charitable purpose, or event: Business Expo in the City of Carson Women's Health Conference and S. Amendment Description or Comments In 2015 CPUC Member Lula Davis Holmes requested CVS Corporation to make a monetary donation to CCCAF for the purpose of co -sponsoring a Women's Health Conference and Business Expo on Saturday, October 16, 2015 at the Carson Community located in the City of Carson 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 November 25, 2015 By DATE FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public 1. Elected Officer or CPUC Member (Last name, First name) Lula Davis Holmes 959 E. Gladwick Street Carson, California 90746 (!Name and title, if different) Area Code/Phone Number I E-mail (Optional) 310 631-0504 .Com r­LUEIVED I T\ / r -r I r-- r-, r , sehested Payment Report 15 NO Y 25 PM 2: 3 For Official Use Only M ❑ Amendment (see Part 5) Date of Original Filing: Nov. 25, 2015 (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Shell Oil Products US Name 20945 S. Wilmington Ave Carson CA 90810 Address city state Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Cultural Arts Foundation Name 603 B University Drive PMB 302 Carson CA 90746 Address city state Zip Code 4. Payment Information (compreleall informa6on.) Date of Payment: $12012015 Amount of Payment: (!n-KindFMV) $ 15,000.00 (month, day, year) (Round to whole dollars.) Payment Type: ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Festival in the City of Carson Jazz and Breast Cancer Awareness 5. Amendment Description or Comments In 2015 CPUC Member Lula Davis Holmes requested Shell Oil Products US to make a monetary donation to CCCAF for the purpose of co -sponsoring a Jazz and Breast Cancer Awareness Festival in the City of Carson on Saturday, October 3, 2015 at Anderson Park 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. November 25, 2015 Executed on By DATE SIGNATURE OF ELECTEC FPPC Farm 803 (Decemberl09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Docume 1. Elected Officer or CPUC Member (cast name, First name) Lula Davis Holmes Aaencv Name City of Carson 701 E Carson STREET Area Code/Phone Number 310 6310504 (Marne and title, if different) E-mail[ (Optional) LHOLMES959@AOL.COM 1.1 I I Y CLERK 2015NOV 10 PM 3: 39 QrY OF ❑ Amendment (See Part 5) Date of Original Filing: 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Tosoro Refinary Name Behested Payment Report For Official Use Only 11-9-2015 (month, day, year) 2350 E. 223rd St Carson Ca 90810 Address City state Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Cultud Arts Foundation Name 603 B University Drive PMB 302 Carsn Ca 90746 Address city State Zip Code 4. Payment Information (completeauintomration.) Date of Payment: June 26, 2014 (month, day, year) Amount of Payment: (!n-Kfndrmiq $ $5000.00 (Round to whole dollars.) Payment Type: ® Monetary Donation Brief Description of In -Kind Payment: or ❑ In -Kind Goods or Services (Provide description below.) Purpose: (Check one and provide description below.) ❑ Legislative ❑ Governmental ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co Sponsorship of following Events 2014 Juneteenth celbration for $5,000, 5. Amendment Description or Comments IN 2014 CPUC Member Lula Davis Holmes requeted that Tosoro to make a monetary donaton totaling $5,000 -g CCC 4Ae for the Following events. Juneteenth Celebration $5,000. 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 November 9, 2015 DATE FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Document 1. Elected Officer or CPUC Member (Lost name, First name) Lula Davis Holmes City of Carson Agency Street Address 701 E Carson STREET Desionated Contact Persi Area Code/Phone 310 6310504 if different) E-mail (Optional) LHOLMES959@AOL.COM Behested Payment Report UI I Y 'FJI&cial Use Only 101NOV 10 1113:39 CITY O C s ❑ QN Amendment (See Part 5) Date of Original Filing: 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Tosoro Refinary Name 11-9-2015 (month, day, year) 2350 E. 223rd St Carson Ca 90810 Address City State Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Culturl Arts Foundation Name 603 B University Drive PMB 302 Carsn Ca 90746 Address City Stale Zip Code 4. Payment Information fcompleteallinformation.) Date of Payment: Payment Type: July 7,2015 (month, day, year) Amount of Payment: (ln-1jndFMv* $ $10,000.00 fRound to whole dollars.) ® Monetary Donation or ❑ In -Kind Goods or Services (Provide description below) Brief Description of In -Kind Payment: Purpose: (Check one andprovide description belowj ❑ Legislative ❑ Governmental ® Charitable Describe the legislative, governmental, charitable purpose, or event: 2015 Juneteenth celbration 5. Amendment Description or Comments Co Sponsorship of following Events IN 2015 CPUC Member Lula Davis Holmes requeted that Tosoro to make a monetary donaton for the Following events. Juneteenth Celebration $2015. Organization submitted a grant application and was awarded $10,000.00 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 November 9, 2015 DATE FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8651275-3772) Behested Payment Report A Public Document _ 1. Elected Officer or CPUC Member (Last name, First name) "� ris Lula Davis Holmes CITY CLER of Carson Area Code/Phone Number 310 631-0504 (Name and title, if E-mail (Optional) tol rl11 15 NOV 10 PH 3: J8 OF Behested Payment Report For Official Use Only ❑ Amendment (see Part 5) Date of Original Filing: //— (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Waste Management Name 1970 E. 213th Street Carson Ca 90 90810 Address City State Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizens Cultural Arts Foundation Name 603 B University Drive PMB 302 Carson Ca 90746 Address City State Zip Code 4. Payment Information (Complete all information.) Date of Payment: 10/14/2013 Amount of Payment: (!n-wndFMv) $ 5,000.00 (month, day, year) (Round to whole dollars.) Payment Type: ® Monetary Donation or ❑ In -Kind Goods or Services (Pmvide description below) Brief Description of In -Kind Payment: Purpose: (Check one and provide description below) ❑ Legislative ❑ Governmental ❑ Charitable Describe the legislative, governmental, charitable purpose, or event: CO sponsorship of the Juneteenth celebration in 2014 in the amt of $2500.00 and the Jazz Festival in 2014 in the amount of $25000.00 Total $5,000.00 5. Amendment Description or Comments In 2014 CPU Member Lula Davis Holmes requested that Waste Management make a monetary donation whhich totaled $5,00.00 for the 2014 Juneteenth celebration received $2500.00 on 9/27/2014 and on 10/14/2014 revive and Additional $2500.00 for the Jazz Festival on 10114 for the Carson citizens Cultural Arts foundation 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. ! S Executed on By DATE SIGNATUF OR CPUC MEMBER FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661276-3772) Behested Payment Report A Public Docu 1. Elected Officer or CPUC Member (Last name, First name) Lula Davis Holmes City of Carson 701 ECarson STREET Area Code/Phone Number 310 6310504 (Name and title, if different) E-mail (Optional) OLMES959@AOL.COM TY CLERK Z�NOY 10 PH 3: 39 red ❑ Amendment (see Parts) Behested Payment Report For Official Use Only Date of Original Filing: 11-9-2015 (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Waste Management Name 1970 E. 213th Street Carson Ca 90745 Address City Slate Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Cultud Arts Foundation Name 603 B University Drive PMB 302 Carsn Ca 90746 Address City State Zip Code 4. Payment Information (complete aninformation.) Date of Payment; Payment Type: Sept 8, 2014 (month, day, year) Amount of Payment: (ln-xlndM9 $ $8500.00 (Round to whole dollars.) ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co Sponsorship of following Events Juneteenth June 13 2014for $2500, Jazz Festival Sept. 8 2014 FOR $5,000, Turkey Give Away $1,000 S-rL 5. Amendment Description or Comments IN 2014 CPUC Member Lula Davis Holmes requeted that Waste Management make a monetary donaton totaling $8500 for the Following events. Juneteenth Celebration $2500.00. The Jazz Festival $5,000, Turkey Give Away $1,000 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 November 9, 2015 By 64�) DATE SIGNATURE OF ELECTI FPPC Form 803 (December/09) FPPC Tall -Free Helpllne: 866/ASK-FPPC (8661275-3772) Behested Payment Report A Public Docum 1. Elected Officer or CPUC Member (Last name, First name) Lula Davis Holmes City of Carson 701 ECarson STREET Area Code/Ph 310 6310504 (Name and title, if different) E-mail (Optional) LHOLMES959@AOL.COM Behested Payment Report !TY CLERK For Official Use Only 20151NOV 10 PH 3: 39 C1W OF CAHSON ❑ Amendment (see Part 5) Date of Original Filing: 11-9-2015 (month, day, year) 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Waste Management Name 1970 E. 213th Street Carson Ca 90745 Address City Stale Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Carson Citizen Culturi Arts Foundation Name 603 B University Drive PMB 302 Carsn Ca 90746 Address City State Zip Code 4. Payment Information (Complereall information.) Date of Payment: Sept 17, 2015 Amount of Payment: (In-xndMO $ $7500.00 (month. day, year)(Round to whole dollars.) Payment Type: ® 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 ® Charitable Describe the legislative, governmental, charitable purpose, or event: Co Sponsorship of following Events Juneteenth June 04 2015 FOR $2500, Jazz Festival Sept. 17, 2015 FOR $5,000, Tota 1$7500 5. Amendment Description or Comments IN 2015 CPUC Member Lula Davis Holmes requeted that Waste Management make a monetary donaton totaling $7500 for the Following events. Juneteenth Celebration $2500.00. The Jazz Festival $5,000 6. Verification 1 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 November 9, 2015 DATE VVE %" FPPC Form 803 (December/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772)