Art3_Yucaipa_FY17_BikePed_OakGlen_Inv1a_240703_rejected - not signed or consistent w docsClaimant: City of Yucaipa Date:
Please see below instructions and checkmark the items included in your submittal.
1. Claim Form (one-time submission)
Please submit a completed Claim Form prior to requesting reimbursement of funds. An authorizing
resolution is required with the Claim Form (see #2).
2. Authorizing Resolution (one-time submission)
Resolution authorizing the filing of the claim form and authorizing the submission of reimbursement
requests throughout the duration of the project. Please submit resolution with Claim Form.
3. Reimbursement Request Form (as needed)
This form is required for every reimbursement requested.
4. Back-up Documentation (required with Reimbursement Request Form)
Please attach documentation supporting the amount requested (e.g., invoices, paychecks,
purchase orders, etc.)
5. Certified Copy of Minute Action (completed projects only)
Certified copy of minute action authorizing the filing of the final claim and verifying project completion.
6. Photos of Completed Project (completed projects only)
7. Other (optional)
Attach any other information you wish to submit to support your claim.
Project Name: Oak Glen Rd Bike & Pedestrian Facility Grant Allocation No: L18-0702-0752-00
Claimant: City of Yucaipa
Address: 34272 Yucaipa Blvd
Attention:
Phone No: (909) 797-2489
E-mail Address: kkunkel@yucaipa.org
Amount Requested for Reimbursement:
89728
Purpose: Please check one purpose.
(X) Article 3 Bicycle/Pedestrian Facilities, Public Utilities Code (PUC) 99233.3
( ) Transit Stop Access Improvements, PUC 99233.3
Authorizing Signature:
(Claimant's Chief Adminstrator or Financial Officer)
Date:
Signature
Fermin Preciado, Director of Development Services/City Engineer
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.
Claimant: City of Yucaipa
Grant Information (completed by SANBAG)
Project Name Total Project Cost Article 3 Award Amount Percent Article 3 Local Match Amount Percent Local Match
Oak Glen Rd Bike & Pedestrian Facility 138043 89728 0.650000362205979 48315 0.349999637794021
Instructions: Please complete 1 through 4 below.
Amount
1) Article 3 Project Cost (amount being requested for reimbursement) 89728
2) Local Match Project Cost 62030
Total 151758
Project Costs to Date (include amount requested above)
3) Article 3 89728 Local Match Amount Remaining 8971.15
4) Local Match 39343.85 Article 3 Balance Remaining 0
Total 129071.85 Total Amount Remaining 8971.15
I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
The same authority that signs the Claim Form must sign this form.
Signed: Date:
IE Engineering Construction Contract 121785
Bike Rack 485.69
Picnic Bench 958.99
Staff Time 5842.17
129071.85