801 Payment to Agency Report (Health and Wellness Fair) 11-14-24Payment to Agency Report A Public Docu
1. Agency Name
City of Cupertino
Division, Department, or Region (if applicable)
Human Resources
Street Address
10300 Torre Avenue
Area Code/Phone Number
408-777-3200
agency Contact (name and title)
Kirsten Squarcia, City Clerk
Email
kirstens@cupertino.gov
TO AGENCY REPORT
NOV 1 ^ ' 24 IIU or Official Use Only
C*RTINO CITY CLERK
2. Donor Name and Address
0 Individual See Attached List ❑ Other
Last Name First Name
❑ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
Name
Address City State Zip Code
If "Other" is marked, describe the entity's business activity (if business) or its nature and interests.
� If applicable, identify the name of each source and the amount(s) received by the donor for this payment:
(See attached itemized list) $ $
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.
Items that were donated for the 2024 City of Cupertino employee Health and Wellness Fair. Items
were received by City staff for wellness use.
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 auth *zed the acceptance of the reported payment(s) as in compliance with FPPC regulations
—mil ttvp F0�6mela Wu City Manager
K(fiLook
Signature Print Name Title
Comment:
/i/11// 2- 2-t
(month, day, year)
(Use this space or an attachment for any additional information)
Clear Pa e
FPPC Form 801 (Jan/18)
advice@fppc.ca.gov
Form 801 Itemized List
Donated By
Item
Estimated
Value
Vision Service Plan
Women's Converse Sunglasses (similar
item)
$32.80
Nationwide 457 Deferred Comp
Pickleball Paddle Set of 2 (similar item)
$38.25
New York Life
NY Lo _o La top Backpack (similar item)
$16.99
Delta Dental
Cordless Water Flosser (similar item)
$37.99
PRN Ergonomic Services
$25 Starbucks Gift Card
$25.00
Santa Clara County Federal
Credit Union
$25 Starbucks Gift Card
$25.00
Colonial Life
$25 Starbucks Gift Card
$25.00
MissonSquare 457 Deferred
Comp
$25 Amazon Gift Card
$25.00
Dr. Ryan Senft, DDS
Cordless Water Flosser (similar item)
$49.99
Habit Burger
3 Charburger Vouchers
$24.00
Starbucks
1 Coffee Traveler
$20.00