Art3_Omnitrans_FY11_Transit_10stops_InvSan Bernardino County Transportation Commission
Local Transportation Fund - Article 3 Pedestrian, Bicycle Facilities
and Access to Transit
Claim Form
Art3Claim-StopAccess-Omnitrans
Check List Page 1
Claimant:City of Omnitrans Date:
1.Claim Form
2.Financial Reporting Form
3.
4.
5.Project Completion Report
6.Other (optional)
13Art3Claim-StopAccess-Omnitrans
(List any other information you wish to submit to support your claim)
Request for Progress Payment (projects over $200,000)
(Certified copy of resolution or minute action authorizing the filing of the claim and
requesting progress payments)
(Certified copy of minute action or resolution authorizing the filing of the claim and
Project acceptance)
The Check-List below are items that must be included with your submission for reimbursement
(Complete the estimated column for anticipated interest, refunds and expenditures)
Governing Body Authorization (Completed Projects)
(Council's Project acceptance can be used. Pictures of completed project must be
included.)
San Bernardino County Transportation Commission
Local Transportation Fund - Article 3
Pedestrian, Bicycle Facilities and Access to Transit
Claim Form
Art3Claim-StopAccess-Omnitrans
Claim Form
Page 2
Fiscal Year:FY 2013/2014
Claimant:Attention:
Phone #:
mailto:
Amount:#REF!
PURPOSE:
(Signature)
Omnitrans Anna Rahtz
1700 West Fifth Street
San Bernardino CA 92411 anna.rahtz@omnitrans.org
Approval of this claim and payment by the County Auditor to this claimant are subject to monies being
available and to the provision that such monies will be used only in accordance with the allocation
instruction.
(Type Name & Title
Condition of Approval:
( ) Article 3, PUC Section 99234a Pedestrian Facilities
( ) Article 3, PUC Section 99234a Bicycle Facilities
( X ) Article 3, PUC Section 99234a Pedestrian Access to Transit Facilities
Authorizing Signature:
(Claimant's Chief Adminstrator or Financial
Officer)
San Bernardino County Transportation Commission
Local Transportation Fund - Article 3
Bicycle, Pedestrian and Access to Transit
Financial Reporting Form
Art3Claim-StopAccess-Omnitrans Page 3
Claimant:Date:
Project %Project
Budget TDA Actual
Cost Budget Cost
1. Project Name: Total Project Expenditure 39,200$ -$
TDA Article 3 (SB 821) 31,360$ 0%-$
* Local Match 7,840$ -$
2. Project Name: Total Project Expenditure 2,920$ -$
TDA Article 3 (SB 821) 2,336$ 0%-$
Local Match 584$ -$
3. Project Name: Total Project Expenditure 20,020$ -$
TDA Article 3 (SB 821) 16,016$ 0%-$
Local Match 4,004$ -$
4. Project Name: Total Project Expenditure 1,859$ -$
TDA Article 3 (SB 821) 1,487$ 0%-$
Local Match 372$ -$
5. Project Name: Total Project Expenditure 1,859$ -$
TDA Article 3 (SB 821) 1,498$ 0%-$
Local Match 361$ -$
6. Project Name: Total Project Expenditure 2,359$ -$
TDA Article 3 (SB 821) 1,887$ 0%-$
Local Match 472$ -$
Vineyard Ave and Foothill
Blvd
Foothill Blvd and Grove Ave
Omnitrans
Inland Regional Center Bus
Stop Imprvmts
Foothill Blvd and Campus
Ave
Baseline Street and Victoria
Ave
Riverside Dr and Archibald
Ave
San Bernardino County Transportation Commission
Local Transportation Fund - Article 3
Bicycle, Pedestrian and Access to Transit
Financial Reporting Form
Art3Claim-StopAccess-Omnitrans Page 3
7. Project Name: Total Project Expenditure 12,527$ -$
TDA Article 3 (SB 821) 10,022$ 0%-$
Local Match 2,505$ -$
8. Project Name: Total Project Expenditure 1,859$ -$
TDA Article 3 (SB 821) 1,487$ 0%-$
Local Match 372$ -$
9. Project Name: Total Project Expenditure 2,359$ -$
TDA Article 3 (SB 821) 1,887$ 0%-$
Local Match 472$ -$
10. Project Name: Total Project Expenditure 13,000$ -$
TDA Article 3 (SB 821) 10,400$ 0%-$
Local Match 2,600$ -$
I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
Signed:
Euclid Ave and Fifth St
Boulder Ave and Highland
Ave
Baseline Rd and Valeria Ave
Baker Ave and Fourth St