RECEiVhil- Behested Payment Report Behested Payment Report A Public Dbcnir7l%ntQ,^., CAnr-'yi 1. Elected Officer or CPUC Member (Last name, First name) Date Stamp California < Mayor Sam Liccardo m\ HAY IForm ’ ! I PM 2: 41 For Official Use Only Agency Name City of San Jose Agency Street Address 200 E. Santa Clara, San Jose, CA, 95113 Designated Contact Person (Name and title, if different) I I Amendment fSee Part 5; Henry Smith Date of Original Filing: Area Code/Phone Number E-mail (Optional) (month, day, year) 4085354831 [email protected] 2. Payor Information (For additional payors, include an attachment with the names and addresses.) Dan Kingley Name 601 California St# 1310 San Francisco CA 94108 Address City state Zip Code 3. Payee Information (For additional payees, include an attachment with the names and addresses.) Innovation For Everyone Name 5429 Madison Ave Sacramento CA 95841 Address City State Zip Code 4. Payment Information (Complete aiiinformation.) 8/31/20 10,000 Date of Payment: Amount of Payment: (in-KindFMV) $ (month, day, year) (Round to whole dollars.) Payment Type: [HI Monetary Donation or □ In-Kind Goods or Services (Provide descnpuon below.) Brief Description of In-Kind Payment: Purpose: (Check one and provide description below.) □ Legislative □ Governmental HI Charitable Innovation for Everyone Describe the legislative, governmental, charitable purpose, or event: Community 5. Amendment Description and/or Comments 6. 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. s h U\ A Executed on By DATE S1GN;^URE OF ELECTED OFFICER OR CPUC MEMBER FPPC Form 803 (January/ZOlS) FPPCToll-Free Helpline: 866/ASK-FPPC (866/275-3772).