801 Payment to Agency Report (Pineapple Thai Restaurant) 03-11-24Payment to Agency Report A Public Doc
1. Agency Name
City of Cupertino
Division, Department, or Region (if applicable)
City Manager
Street Address
10300 Torre Ave., Cupertino CA 95014
Area Code/Phone Number Email
408-777-3225 1 kirstens@cupertino.org
AgenCy L;ontact (name and title)
Kirsten Squarcia, City Clerk
2. Donor Name and Address
TO AGENCY REPORT
MAR 1 1 2024 II �fr Official Use Only
CUO'ERTINO CITY CLIP RK
❑ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
❑ Individual ® Other Pineapple Thai Restaurant
Last Name First Name Name
Cupertino CA 95014
Address City State Zip Code
Restaurant business that prepares and serves food and drinks onsite and takeout.
If "Other" is marked, describe the entity's business activity (if business) or its nature and interests
- 0 If applicable, identify the name of each source and the amount(s) received by the donor for this payment:
$ 500.00 $
Name Amount Name Amount
3. Payment Information (Complete Sections 3.1 (a or b), 3.2, 3.3)
3.1 (a) Travel Payment
Location of Travel Dates (month, day, year)
❑ Rail ❑ Air ❑ Bus ❑ Auto ❑ Other
Transportation Provider Check Applicable Boxes Name of Lodging Facility
$ $ $ $ $
Lodging Expenses Meal Expenses Transportation Expenses Other Expenses Total Expenses
3.1 (b) Payment(s) not related to travel: $
Dates (month, day, year)
Total Expenses
3.2. Payment Description. Provide. a specific description of the payment and its agency purpose and use.
Food donation for all attendees of the Cupertino Swearing -in -Ceremony held on 2/15/24.
3.3. Identify the officials who used the payment in Section 3.1 (See instructions)
Last Name First Name Position/Title Department/Division
Last Name First Name Position/Title Department/Division
4. Verification
I authoriAd the acceptance of the reported payment(s) as in compliance with FPPC regulations.
rl�� Pamela Wu City Manager 03/11/24
11 Signature Print Name Title (month, day, year)
(Use this space or an attachment for any additional information)
FPPC Form 801 (Jan/18)
advice@fppc.ca.gov