Nonprofit Travel Payments, Advances and Reimbursements
Donor Disclosure List
A Public Document
807
California
1. Nonprofit Organization Information
501(c)(3)
501(c)(4)
Date Stamp
Form
For Official Use Only
Name of Organization
Street Address
Designated Contact Person (Name and title)
Amendment (See Part 3)
Date of Original Filing:
Area Code/Phone Number
Email
(month, day, year)
2. Donor Information (For additional donors, include an attachment with the information)
Name of Donor
Street Address
Elected Official’s Name and Position
Travel Destination and Purpose
Name of Donor
Street Address
Elected Official’s Name and Position
Travel Destination and Purpose
3. Amendment Description and/or Comments
4. 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.
Date Signed:
Signature:
FPPC Form 807 (June/2016)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)