HomeMy Public PortalAbout10-14-19 - Davis-Holmes, Lula (2)Behested Payment Report A Public Document
1. Elected Officer or CPUC Member (Last name, First name) Date Stamp
Lula Davis Holmes
City of Carson
701 e. Carson Street
Area Code/Phone Number
310 629-9158
and title,
E-mail (Optional)
«19 OCT It, Ply 1- 0
❑ Amendment (See Pari 5)
Date of Original Filing:
2. Payor Information (For additional payors, include an attachment with the names and addresses.)
Phillips 66
eehested Payment Report
For Ottldal Use Only
10-14;2019
(month, day, year)
Name
1660 W.Anaheim Street Wilmington Ca 90744
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
P.O. Box 4573 Caraon Calif 90746
Address City Slate Zip Code
4. Payment Information (corrrpleteall intarmationj
Date of Payment: Sept 2019 Amount of Payment: #n-wndFMv) $ 5,000
(month, day, year) (Round to whole dollars.)
Payment Type: 0 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 0 Charitable
Describe the legislative, governmental, charitable purpose, or event: Octoer 5,2019 Jazz Festival
5. Amendment Description and/or Comments
fi. 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 October 14, 2019 By
DATE
SIGNATURE OF R ECTED OFFICER OR CPUC MEMBER
FPPC Form 803 (January/2018)
FPPC Toll -Free Helpfine: 866/ASK-FPPC (866/275-3772)