Fill and Sign the Confidentiality Agreement Jacksonville State University Form

Tickets Provided by Agency Report A Public Document 1. Agency Name TICKETS PROVIDED BY AGENCY REPORT Date Stamp California Form 802 For Official Use Only Division, Department, or Region (if applicable) Street Address Area Code/Phone Number E-mail Amendment (explain in comment section) Agency Contact (name and title) Date of Original Filing: (month, day, year) 2. Event For Which Tickets Were Distributed Date of Event: / / Description of Event: / / Cost of Admission: $ Agency Event Yes t f a No (Identify source of tickets below.) Name of Outside Source of Ticket(s) Provided to Agency: Number of Tickets Received: r D Ticket(s) Provided to Agency: Gratuitously Pursuant to Contract 3. Agency Official(s) Receiving Ticket(s) (use continuation sheet for additional names) Name of Official (Last, First) Number of Tickets Governmental or Public Purpose for Distribution 4. Individual or Organization Receiving Ticket(s) (at the behest of an agency official) Name of Behesting Agency Official: Name of Individual or Organization: Number of Tickets Description of Organization: Address of Organization: Number and Street City State Zip Code Purpose for Distribution: (Describe the governmental or public purpose for the distribution to the organization.) 5. Verification I have determined that it is in the interests of the agency to accept this gift and use it for the official agency business described above. Signature of Agency Head or Designee Print Name Title (month, day, year) Comment: (Use this space or an attachment for any additional information.) FPPC Form 802 (draft-Dec/08) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772) Tickets Provided by Agency Report California Form 802 A Public Document This form is for use by all state and local government agencies to disclose the distribution of tickets or passes that allow admission to facilities, events, shows, or performances for entertainment, amusement, recreational, or similar purposes. The agency must complete Form 802 identifying agency officials who receive tickets or passes from the agency as well as other individuals and organizations that receive tickets or passes at the behest of agency officials. Form 802 must be posted in a prominent fashion on the agency’s website. Gratuitously (see Regulation 18944.1(b)(2)), or Pursuant to a contract (see Regulation 18944.1(b)(3)). Part 3. Agency Official(s) Receiving Ticket(s) Disclose the name of each agency official that received a ticket or pass and the number of tickets or passes the official received. Also describe the governmental or public purpose for which the official received the tickets or passes. t f a Gifts of Tickets or Passes to Public Officials: FPPC Regulation 18944.1 sets out the circumstances under which an agency’s distribution of tickets or passes to or at the behest of an official in the agency does not result in a gift to the official. (Regulation 18944.1 is available on the FPPC website at www.fppc.ca.gov.) Even though the distribution of tickets or passes to a public official under the regulation is not a gift to the official, the agency must disclose the distribution on Form 802. The official does not have to disclose tickets or passes received or distributed under the regulation on his or her Statement of Economic Interests (Form 700), but tickets or passes received or distributed by the official that do not fall under the regulation may be subject to disclosure on the official’s Form 700 and subject to gift limits. r D • • Posting Form 802 The Form 802 must be posted on the agency’s website within 30 days after the distribution. If the agency does not maintain a website, the form must be maintained by the agency as a public record, be available for public inspection and copying, and be forwarded to the FPPC for posting on its website. 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. Event For Which Tickets Were Distributed Provide the date(s) of the event, a description of the event, and the cost of admission. Check the box indicating whether the event was an “agency event” (such as a county fair, or an event for which the agency purchased tickets). If the agency received the tickets from an outside source, identify the source, the number of tickets received, and check the box to identify whether the tickets or passes were provided to the agency: Part 4. Individual or Organization Receiving Ticket(s) If tickets or passes were distributed to an individual or organization outside the agency at the behest of an official of the agency, provide the name of the official. Disclose the name(s) of the individuals(s) who received the tickets or passes and the number of tickets or passes provided. If the tickets or passes were provided to an organization, the agency may post the name, address, a description of the organization, and the number of tickets or passes provided to the organization in lieu of posting the name of each individual that received a ticket or pass. Also describe the governmental or public purpose for the distribution to the individual or organization. Part 5. Verification The agency head or his or her designee must sign the form. Privacy Information Notice Information requested on all FPPC forms is used by the FPPC to administer and enforce the Political Reform Act (Government Code Sections 81000-91014 and California Code of Regulations Sections 18109-18997). All information required by these forms is mandated by the Political Reform Act. Failure to provide all of the information required by the Act is a violation subject to administrative, criminal, or civil prosecution. All reports and statements provided are public records open for public inspection and reproduction. If you have any questions regarding this Privacy Act Notice, please contact the FPPC. General Counsel Fair Political Practices Commission 428 J Street, Suite 620 Sacramento, CA 95814 (916) 322-5660 FPPC Form 802 (draft-Dec/08) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)