Art3_Fontana_FY23_Transit_10 Bus Pads_ClaimClaimant:
Please see below instructions and checkmark the items included in your submittal.
1.
2.
3.
4.
5.
6.
7.
8.
City of Fontana
Claim Form (one-time submission) – required prior to, or along with, your first reimbursement request.
Authorizing Resolution (one-time submission) – required within SIX months of the project award by SBCTA Board or prior to requesting reimbursement of funds, whichever comes first. Resolution
should authorize the filing of the claim form, authorize the submission of reimbursement requests and designate the individuals authorized to certify project completion (Authorized
Agent). Sample language is available upon request.
Reimbursement Request Form (as needed) – this form is required every time a reimbursement is requested. Please note, progress payments are only eligible on awards over $200,000, the
requested amount must be a minimum of 20% of the award total, and the local match share percentage must be met regardless of reimbursement amount requested.
Backup Documentation (required with Reimbursement Request Form) – invoices, paychecks, purchase orders, etc. to support both the reimbursement and match amounts noted on the Reimbursement
Request Form. Please note, staff administration and/or contract project management expenses are NOT eligible match expenses. However, staff expenses may qualify for local match under
select circumstances. Please identify whether supporting documentation includes staff expenses under one of the following allowable conditions:
Backup Summary itemizing reimbursement request expenses.
Certification of Completion (completed projects only) – prior to filing the final request for reimbursement, written verification of project completion by the agency’s Authorized Agent
is required (see Authorizing resolution above). Sample language is available upon request.
Photos of Completed Project (completed projects only) – required when project is complete and should be attached to final reimbursement request.
Other (optional) – Claimants may attach additional information not included in this list to support the claim or reimbursement request. SBCTA may request additional information as necessary.
Award is for an ATP Safe Routes to School (SRTS) program project, not a SRTS infrastructure project.
Necessary staff time directly related to in-house completion of design, right-of-way acquisition, or construction including inspection and/or construction management.
Note: No travel costs or per diems allowed for staff time
Date:
Project Name:
Claimant:
Address:
Attention:
Phone No:
E-mail Address:
Award Amount
Purpose:
Authorizing Signature:
(Authorized Agent specified in Authorizing Resolution)
Signature
Type Name & Title
Condition of Approval:
Approval of this claim and payment by the County Auditor to this claimant are subject to monies being available and to the provision that such monies will be used only in accordance
with the approved allocation instruction.
10 Bus Pads in the City of Fontana
City of Fontana
59023
Please check one purpose.
Article 3 Bicycle/Pedestrian Facilities, Public Utilities Code (PUC) 99233.3
Transit Stop Access Improvements, PUC 99233.3
Date:
Grant Allocation No:
L24-0702-0737-00
Claimant:
Section I: Required for all Reimbursement Requests (1-5)
Grant Information (completed by SBCTA)
Project Name
10 Bus Pads in the City of Fontana
A: Current Request for Reimbursement
TDA Article 3 Reimbursement Amount Requested
Local Match
ATP Funds Utilized
1) Total Spent*
*Shares will be automatically calculated based on non-rounded formula.
B: Project Costs to Date (include amount requested above)
2) TDA Article 3
3) Local Match
4) ATP (if applicable)
Total
C: Balance Remaining
TDA Article 3
Local Match
ATP Funds (if applicable)
Total
5) Check to verify expenses claimed are consistent with the approved scope.
Bus Pads at:
1. Slover & Sierra WB
2. Citrus & Mallory NB
3. Citrus & Mallory SB
4. Baseline & Village EB
5. Baseline & Heritage WB
6. Sierra Lakes & Tiburon EB
By signing below, I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
Signed:
City of Fontana
(Authorized Agent specified in Authorizing Resolution)
7. Sierra Lakes & Tiburon WB
8. Jurupa & Elm WB
9. Merril & Locust EB
10. Merrill & Cypress WB
Total Project Cost
84319
0
0
0
0
59023
25296
0
84319
No. of Bus Pads
Article 3 Award Amount
59023
Minimum progressive reimbursement amount 20%
11804.6
Enter total only
0
0
0
0
1
1
0
1
10
Section II: Required for Progressive Reimbursements ONLY (1-3)
A: Project Completion (turns red if % completed is significantly less than invoice)
B: Summary of Project Status
3) If either number turned red above, please provide a project schedule that demonstrates how the project will be completed on schedule within the budget. Provide attachments as needed.
Allocation #:
Percent
Article 3
0.699996442083042
1) Overall % Completed
2) Mileage Completed (if applicable)
Date:
L24-0702-0737-00
Local Match
25296
ATP Funds
(if applicable)
0
Share Completed:
0
Project Title:
Date
Total
10 Bus Pads in the City of Fontana
Recipient's Name
Brief Description of Purchase
Amount
(include proof of payment)
0
Allocation Number
- select -
L24-0702-0730-00
L24-0702-0737-00
L24-0702-0741-00
L24-0702-0744-00
L24-0702-0748-00
L24-0702-0751-00
L24-0702-0751-01
L24-0702-0751-02
L24-0702-0754-00
L24-0702-0755-00
L24-0702-0755-01
L24-0702-0755-02
L24-0702-0755-03
L24-0702-0755-04
L24-0702-0755-05
L24-0702-0755-06
Claimant
-
City of Adelanto
City of Fontana
City of Loma Linda
City of Ontario
City of San Bernardino
VVTA
VVTA
VVTA
County of San Bernardino
Omnitrans
Omnitrans
Omnitrans
Omnitrans
Omnitrans
Omnitrans
Omnitrans
Project Name
-
Transit Improvements at Jonathan Street
10 Bus Pads in the City of Fontana
11 Bus Stops in the City of Loma Linda
Ontario Improvements: Three Improvement Grants
Bus Stop Sidewalk Improvements
Apple Valley Bus Stop Improvements
Victorville - Sunhill Drive & Chalon Road
Victorville - Nevada Avenue & McCoy Circle Drive
Bus Stop Improvements on Pacific Street
Benches/Shelters for the City of Colton
Benches/Shelters for the City of Highland
Benches/Shelters for the City of Montclair
Benches/Shelters for the City of Ontario
Benches/Shelters for the City of Redlands
Benches/Shelters for the City of Rialto
Benches/Shelters for the City of Yucaipa
Total Project Cost
0
172000
84319
62652
32835
120000
160003
95100
12952
130000
117600
112000
144000
108776
111200
128800
32000
Art 3 Award Amount
0
144000
59023
50122
32835
96000
128002
76080
10362
90000
117600
112000
144000
108776
112000
128800
32000
ATP Funds
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0