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2012 Humana Challenge - Dinner & Concert EventAgency Report of: Ceremonial Role Events and Ticket/Admission Distributions 1. Agency Name City of La Quinta Division, Department, or Region (if applica.t Street Aaa ress 78-495 Calle Tampico, La Quinta, CA 92253 Designated Agency Contact (Name, Title) Mark Weiss, Interim City Manager Area Code/Phone Number E-mail 760-777-7100 mweiss@la-quinta.org 2. Function, Event, or Ceremonial Role Information Title 2012 Humana Challen Description Dinner and Concert Event A Public Document Date stamp For Official Use only I ❑ Amendment (Most provide explanation in Part 3.) Date of Original Filing: (month, day, year) Face Value of Each Admission $ 750 Date(s) 01 2� 12 f� Tickets)/Admission(s) provided by agency? Yes ❑ No I] If no: Humana Challenge Name of Source Was the distribution to persons identified below made at the behest of an agency official? Yes ❑ No ❑ If yes: Official's Name (Last. First) and Title The identity of recipient(s) and the explanation: Name • Check the income box If the agency official claims admission as (Last, First) Number of .: .'Agency taxable Income. if th a agency.ofRclal.perforrned a ceremonial role, or Admission(s)/ Official also provide a description. . Organization Ticket(s) If not Income, describe the public purpose, including (Name, Address, Description) ceremonial roles, performed by an agency official, Individual, or or anlzation. Yes d Income Adolph, Don 2 No [j see attached ❑ Yes I] Income Franklin, Kristy 2 No ❑ see attached ❑ Yes 0 Income Henderson, Terry 2 No ❑ see attached ❑ Yes d Income Evans, Linda 2 No ❑ see attached Yes El Income Osborne, Lee 2 No ❑ see attached ❑ 3. Verification 1 have read and understand FPPC Regulations 18944.1 and 98942, 1 have verified that the distribution of admissions, set forth above, is in accordance with the provisions. 6 Mark Weiss Interim City Manager 02/13/2012 Signature of Agency Head or Designee Print Name Title (month, day, year) Comment: (Use this space or an attachment for any additional information including amendment explanation.) FPPC Form 842 (2191) FPPC Toil -Free Helpline: 866/ASK-FPPC (866/275-3772) California Form 802 — Attachment (2012 Humana Challenge (Dinner and Concert Event January 21, 2012) No income. Public purpose for the distribution was for the promotion of The Humana Challenge; City recognition; growth and development; and tourism.