City of Portland City Official Quarterly Statement
December 31 2012
1. City Official Information
2. Gifts, Meals or Entertainment Received
List any gifts, meals or entertainment in excess of $25.00 received from a lobbying entity or any person authorized to lobby on the lobbying entity's behalf, including the name of the lobbying entity and if applicable name of lobbyist, subject of lobbying, value of gift, meal or entertainment, and date of receipt.
No Personal Benefits to Report
I affirm that I have not received any gifts, meals or entertainment in excess of $25.00 from a lobbying entity or authorized lobbyist this calendar quarter.
3. Gifts or Donations Received
List any gifts or donations of personal or real property to the City that a lobbyist or lobbying entity has agreed to make upon request by a City Official including the name of the lobbying entity and if applicable name of lobbyist, gift or donation requested by the City Official, the date of request, and the purpose of the donation.
No City Benefits to Report
I affirm that no lobbying entity agreed to make gifts or donations of personal or real property to the City this calendar quarter based on a request from me.
By signing this document, I acknowledge and affirm under the penalties of false swearing the statements made on this form and that I understand that penalties may be imposed under City Code Chapter 2.12.
City Official signature ____________________________ Date _____________
To complete your registration, please sign and date this statement. Mail or fax the signed statement to:
City of Portland
Office of the City Auditor
1221 SW 4th Avenue Room 320
Portland, OR 97204