Payment to Agency Report

Form 801 Instructions

Use this space or an attachment for an additional information

Part 1 of 4: Agency Information

Part 2 of 4: Donor Name and Address

If applicable, identify the name of each source and the amount(s) received by the donor for this payment.

First Source

Second Source

Part 3 of 4: Payment Information (Complete Sections 3.1 (a or b), 3.2, and 3.3)

Section 3.1 (a): Travel Payment

Type of Transportation

Section 3.1 (b): Payment(s) Not Related to Travel

Section 3.2: Payment Description

Section 3.3: Identify the Officials Who Used the Payment in Section 3.1

First Official

Second Official

Part 4 of 4: Verification

I authorized the acceptance of the reported payment(s) as in compliance with FPPC regulations.

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End of Page, Form 801.