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Behested Payment Report
<br />Form 803 is used by elected officers and members of the
<br />California Public Utilities Commission (CPUC) to disclose
<br />payments made at their behest, principally for legislative,
<br />governmental, or charitable purposes. This form was prepared
<br />by the Fair Political Practices Commission (FPPC) and is
<br />available at www.fppc.ca.gov.
<br />When to File
<br />File Form 803 within 30 days following the date on which the
<br />payment(s) meets or exceeds $5,000 in the aggregate from a
<br />single source in a calendar year. (Section 84224.) Once a single
<br />source has made a behested payment of $5,000 or more
<br />during the calendar year, subsequent payments of any amount
<br />from that source must be reported.
<br />Where to File
<br />State Officials: The official's state agency must receive Form
<br />803 within 30 days of the date the behested payment is made.
<br />Within 30 days after receipt of the report, the state agency
<br />must forward a copy to the FPPC at:
<br />1102 Q Street, Suite 3000, Sacramento, CA 95811
<br />Fax: 916-322-0883 E-mail: Form803CcDfooc.ca.gov
<br />Local Officials: The official's local agency must receive Form
<br />803 within 30 days of the date the behested payment is made.
<br />Within 30 days after receipt of the report, the agency must
<br />forward a copy to the filing officer who receives the official's
<br />original campaign statements.
<br />General Information: Behested payments are payments
<br />made principally for legislative, governmental, or charitable
<br />purposes under Government Code Section 82004.5. These
<br />payments are not for personal or campaign purposes.
<br />Generally, a donation is made at the behest if it is requested,
<br />solicited, or suggested by the official, or otherwise made to
<br />a person in cooperation, consultation, coordination with, or
<br />at the consent of, the elected officer or CPUC member. This
<br />also includes payments behested by the official's agent or
<br />employee on the official's behalf.
<br />Exception: If the behested payment is made by a state, local,
<br />or federal government agency and is principally for legislative
<br />or governmental purposes, the payment does not have to be
<br />reported.
<br />Privacy Information Notice: Information requested by the
<br />FPPC is required by and used to administer and enforce the
<br />Political Reform Act. Failure to provide information may be a
<br />violation subject to administrative, criminal, or civil penalties.
<br />All reports and statements are public records available for
<br />inspection and reproduction. If you have any questions, please
<br />contact the FPPC's General Counsel at 1102 QStreet, Suite
<br />3000, Sacramento, CA 95811 or (916) 322-5660.
<br />Instructions
<br />Part 1- Identification: Identify the official's name, agency,
<br />address, and contact information. Mark the amendment box
<br />if changing information on a previously filed Form 803 and
<br />include the date of the original filing.
<br />Part 2 - Payor Information: Disclose the name and address
<br />of the person making the payment. A business address is
<br />acceptable.
<br />Part 3 - Payee Information: Identify the name and address
<br />of the person receiving the payment. A business address is
<br />acceptable.
<br />Part 4 - Payment Information: Disclose the payment date and
<br />amount using the fair market value (FMV) for donated in-
<br />kind goods or services. Check one box to identify the type of
<br />payment and provide a description if the payment is an in-kind
<br />good or service. Check one box to identify the purpose and
<br />provide a description.
<br />Part 5 - Amendment Description or Comments: Complete this
<br />section if amending a previously filed Form 803 or to provide
<br />additional or clarifying information.
<br />Part 6 - Verification: Date and sign the form under penalty of
<br />perjury.
<br />Example
<br />On April 24, 20XX, at CPUC Member Tully's request, the ABC
<br />Corporation made a monetary donation of $5,000 to the Boys
<br />and Girls Club.
<br />2. Payor Information lfo,.eemmai MMnra.,nnwe an anaanmemmm Me canes endaceresseq
<br />ABC Corporation
<br />1234 Alpha Ave. Saaamento CA 95814
<br />Gry aary „cna.
<br />3. Payee Information lroraamuonawrees, nawce m aexnmea Want me na�nmanc aesresuu
<br />The Boys and Gids Club
<br />Mses
<br />5678 Bravo Biva. Sacramento CA 95814
<br />Mfrem GryMs.no Gwa
<br />4. Payment Information ,cancvs miwwm.an,
<br />Dateof Payment Apnl 24, 20XX Amount of Payment: rv.w,.a.mw g 5.000
<br />Payment Type: ®Monetary DMm= ar ❑ Io-Rlnd Goods or Gemcesnm ...mane—,
<br />Brief Description of In4Dnd Payment:
<br />Purpose: 1-1 a a am--a..n.pa. a -el ❑Leg0ean, ❑Govemmental I@Gbautable
<br />Desedbethe legislative, govemmental, chantable purpose, orevent Donalanlochildmnscommunilyservics
<br />organization
<br />FPPC Form 803 (January/2018)
<br />FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)
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