Payment to Agency Report Instructions

This form is used to report certain payments received by state and local government agencies. It includes:

FPPC Regulations 18944 and 18950.1 provide a procedure that state and local agencies may use to disclose payments used for agency purposes and paid by a third party. The regulations’ reporting procedures provide an alternative means to disclose a payment that may otherwise be considered income or a gift to a benefitting employee and subject to reporting on a Statement of Economic Interest, Form 700.

When and Where to File

An agency accepting a payment pursuant to Regulation 18944 and 18950.1 must complete Form 801 for each payment received regardless of the amount. The form must be maintained as a public document. If payments aggregate $2,500 or more in a calendar quarter, website posting is required.

Website Posting:

State Agencies

Within 30 days after the end of a calendar quarter if aggregated reported payments, for travel and non-travel purposes, total $2,500 or more:

Local Agencies

The website posting rules differ for travel and non-travel payments


Within 30 days after the end of a calendar quarter if aggregated reported payments total $2,500 or more:

Payments Not Related to Travel

The agency’s filing officer for Statement of Economic Interests, Form 700, must receive the report. Within 30 days after the end of a calendar quarter if aggregated reported payments total $2,500 or more, the local agency must post the information on the local agency website. A report is not sent to the FPPC unless the agency does not have a website.

Postings must be displayed in a prominent manner and easily accessible. Reports may be posted earlier


Statements should be emailed for Statements may also be mailed to:

1102 Q Street
Suite 3000
Sacramento, CA 95811
or faxed to (916) 322-3711.

Part 1: Agency Identification

List the agency’s name and address and the name of an agency contact. Mark the amendment box if changing any information on a previously filed form and include the date of the original filing.

Part 2: Donor Information

Disclose the name and address of the donor. If the donor is not an individual, identify the business activity or nature and interests of the entity.

If the donor received funds from other sources that were used in connection with the payment, disclose the name and payment information for each source.

Part 3: Payment Information

Expenses may be rounded to whole dollars

Section 3.1.a

Itemize travel payments including departure and return dates. Complete all fields, use “n/a” appropriately. Total the expenses for items such as taxi rides, gratuities, and rental cars in the “other” field and describe in the comments section.

Section 3.1.b

Report agency payments that are not travel related.

Section 3.2: Description

All payments must include a specific description of the use of the payment and the intended purpose for agency business. For example, a travel payment may read: Travel to attend an EPA co-sponsored solar energy seminar in Washington D.C.

Section 3.3: Identify Officials

Travel Payments: The name of the position/title and department of each official who used the payment is required. List the official’s name if he/she is an elected or appointed official. It is not required to list the names of other officials, rather insert “n/a.” Do not leave blank.

Non-Travel Payments: The name, position/title and department of the agency official who used the payment must be identified. All officials’ names are required.

Part 4: Verification

Verification of travel payments must be signed by an authorized agency official. Such individuals are those who have the authority to approve similar travel payments when made with agency funds.

Verification of non-travel payments msut be signed by the agency head.

Form 801

End of Page, Form 801 Instructions