Fillable Form 801 (California State University Channel Islands)

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Form 801 (California State University Channel Islands)

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The Form 801 (California State University Channel Islands) form is 1 page long and contains:

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  • 3 check-boxes
  • 48 other fields

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File type: PDF

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$
California
Form
Payment to Agency Report
1. Agency Name
Agency Contact (name and title)
Street Address
Amendment
Date Stamp
Email
Division, Department, or Region
(if applicable)
PAYMENT TO AGENCY REPORT
2. Donor Name and Address
Individual
Last Name
First Name
Other
Address City State Zip Code
Name
Name
4. Verication
I authorized the acceptance of the reported payment(s) as in compliance with FPPC regulations.
Signature Print Name
Comment:
FPPC Form 801 (Jan/18)
advice@fppc.ca.gov
(month, day, year)
801
(month, day, year)
For Ofcial Use Only
Area Code/Phone Number
Date of Original Filing:
If “Other” is marked, describe the entity’s business activity (if business) or its nature and interests.
Title
Name
$
3. Payment Information (Complete Sections 3.1 (a or b), 3.2, 3.3)
Amount
Amount
A Public Document
(explain in comment section)
3.1 (a) Travel Payment
Dates (month, day, year)
Location of Travel
Name of Lodging Facility
Transportation Provider
Rail Air Bus Auto
Lodging Expenses
Meal Expenses
Transportation Expenses
$ $ $
3.1 (b) Payment(s) not related to travel: $
Total Expenses
Dates (month, day, year)
3.2. Payment Description. Provide a specic description of the payment and its agency purpose and use.
3.3. Identify the ofcials who used the payment in Section 3.1
(See instructions)
Last Name
First Name
Position/Title
Last Name
First Name
Department/Division
Position/Title Department/Division
Other
Other Expenses
$
$
Total Expenses
Check Applicable Boxes
If applicable, identify the name of each source and the amount(s) received by the donor for this payment:
(Use this space or an attachment for any additional information)
Clear Page
Print Form
click to sign
signature
click to edit
Payment to Agency Report
Instructions
FPPC Form 801 (Jan/18)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
California
Form
801
A Public Document
This form is used to report certain payments received by state and local
government agencies. It includes:
• apaymentforanocial’stravelexpensesforthepurposeof
facilitangthepublic’sbusinessinlieuofapaymentusingagency
funds; and
• apaymentthatwouldotherwisebeconsideredagiorincome
tothebenengocial,butisinsteadacceptedonbehalfofthe
agency.
FPPCRegulaons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regulaons’reporng
proceduresprovideanalternavemeanstodiscloseapayment
thatmayotherwisebeconsideredincomeoragitoabeneng
employeeandsubjecttoreporngonaStatementofEconomic
Interest,Form700.
When and Where to File
AnagencyaccepngapaymentpursuanttoRegulaon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posngisrequired.
Website Posng:
State Agencies
Within30daysaertheendofacalendarquarterifaggregated
reportedpayments,fortravelandnon-travelpurposes,total$2,500or
more:
• the agency must post the reports (or a report summary) on the
agency website; and
• forwardtheinformaontotheFPPCwhichwillalsopostthe
informaon.
Local Agencies
Thewebsiteposngrulesdierfortravelandnon-travelpayments.
Travel
Within30daysaertheendofacalendarquarterifaggregated
reportedpaymentstotal$2,500ormore:
• the agency must post the reports (or a report summary) on the
agency website; and
• forwardtheinformaontotheFPPC.
Payments Not Related to Travel
Theagency’slingocerforStatementofEconomicInterests,Form
700,mustreceivethereport.Within30daysaertheendofa
calendarquarterifaggregatedreportedpaymentstotal$2,500or
more,thelocalagencymustposttheinformaononthelocalagency
website. A report is not sent to the FPPC unless the agency does not
have a website.
Posngsmustbedisplayedinaprominentmannerandeasily
accessible. Reports may be posted earlier.
FPPC:Statementsshouldbeemailedtoform801@fppc.ca.gov.
Statementsmayalsobemailedto1102 Q Street, Suite 3000,
Sacramento, CA 95811orfaxedto(916)322-3711.
Part 1. Agency Idencaon
Listtheagency’snameandaddressandthenameofanagencycontact.
Marktheamendmentboxifchanginganyinformaononapreviously
ledformandincludethedateoftheoriginalling.
Part 2. Donor Informaon
Disclose the name and address of the donor. If the donor is not an
individual,idenfythebusinessacvityornatureandinterestsofthe
enty.
If the donor received funds from other sources that were used in
conneconwiththepayment,disclosethenameandpayment
informaonforeachsource.
Part 3. Payment Informaon
Expensesmayberoundedtowholedollars.
Secon 3.1.a. Itemize travel payments including departure and return
dates.Completeallelds,use“n/a”appropriately.Totaltheexpenses
foritemssuchastaxirides,gratuies,andrentalcarsinthe“other”
eldanddescribeinthecommentssecon.
Secon 3.1.b. Report agency payments that are not travel related.
Secon 3.2. Descripon
Allpaymentsmustincludeaspecicdescriponoftheuseofthe
paymentandtheintendedpurposeforagencybusiness.Forexample,
atravelpaymentmayread:TraveltoaendanEPAco-sponsoredsolar
energy seminar in Washington D.C.
Secon 3.3. Idenfy Ocials
TravelPayments:Thenameoftheposion/tleanddepartmentof
eachocialwhousedthepaymentisrequired.Listtheocial’sname
ifhe/sheisanelectedorappointedocial.Itisnotrequiredtolistthe
namesofotherocials,ratherinsert“n/a.”Donotleaveblank.
Non-TravelPayments:Thename,posion/tleanddepartmentofthe
agencyocialwhousedthepaymentmustbeidened.Allocials’
names are required.
Part 4. Vericaon
Vericaonoftravelpaymentsmustbesignedbyanauthorizedagency
ocial.Suchindividualsarethosewhohavetheauthoritytoapprove
similar travel payments when made with agency funds.
Vericaonofnon-travelpaymentsmustbesignedbytheagencyhead.
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Form 801 (California State University Channel Islands)

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Completed 22 July 2020

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