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3900 Main St, <br />uesignateCl Agency L;o ntact (Name, Title) <br />Pamela Mogan <br />Are Code/Phone Number E-mail <br />951-826-5769 phogan@riversideca,gov <br />2. Function, Event, or Ceremonial Role Information <br />Title One Night of Queen concert <br />Description Fox Performing Arts Center <br />APR 2 0 2011 For MOW Use Only <br />CitY of R�versi&: <br />Cit� Clerk's Offic D <br />❑ Amendment Wustproviote explanation in Part 3j <br />Date of Original Filing: (month, day, year) <br />Face Value of Each Admission $ 53 <br />Date(s) 03 r 11 11 <br />Ticket(s)/Admission(s) provided by agency? Yes El No ❑ If no: <br />Name of Source <br />Was the distribution to persons identified below made at the behest of an agency official? <br />Yes ❑ N o [Z] If yes: <br />Official's Name {Last, First) and Title <br />The identity of recipient(s) and the explanation: <br />Name 0 Check the Income box if the agency official claims admission as <br />(Last, First) Number of Agency taxable income. If the agency official performed a ceremonial role, <br />or Admission(s)l Official also provide a description <br />Organization Ticket(s) 0 If not Income, describe the public purpose, including <br />(Name, Address, Description) ceremonial roles, performed by an agency official, individual, or <br />3. Verification <br />I have ave read and understand FPPC Regulations 18944. and 18942, / have verified that the distribution of admissions, set forth above, <br />i 4 ccordanice with the provisions, <br />Deanna Lorson Director 04111/11 <br />Signature of Agency Head or Designee Print Name <br />Title (month, day, year) <br />Comment: (Use this space or an attachment for any additional information including amendment explanation. <br />FPPC Form 802 (2/11) <br />FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772) <br />Yes [3 <br />Income <br />Davis, Paul <br />No [3 <br />Promotion of the City Profile <br />1:1 <br />Yes ❑ <br />Income <br />No <br />❑ <br />Yes ❑ <br />Income <br />No ❑ <br />❑ <br />Yes <br />Income <br />No ❑ <br />❑ <br />Yes ❑ <br />Income <br />No ❑ <br />r" <br />3. Verification <br />I have ave read and understand FPPC Regulations 18944. and 18942, / have verified that the distribution of admissions, set forth above, <br />i 4 ccordanice with the provisions, <br />Deanna Lorson Director 04111/11 <br />Signature of Agency Head or Designee Print Name <br />Title (month, day, year) <br />Comment: (Use this space or an attachment for any additional information including amendment explanation. <br />FPPC Form 802 (2/11) <br />FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772) <br />