Art3_Omnitrans_FY13_Transit_10stops_ClaimClaimant:
The Check-List below are items that must be included with your submission for reimbursement
13Art3Claim-StopAccess-Omnitrans
1.
2.
3.
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6.
City of Omnitrans
Claim Form
Financial Reporting Form
(Complete the estimated column for anticipated interest, refunds and expenditures)
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)
Governing Body Authorization (Completed Projects)
(Certified copy of minute action or resolution authorizing the filing of the claim and Project acceptance)
Project Completion Report
(Council's Project acceptance can be used. Pictures of completed project must be included.)
Other (optional)
(List any other information you wish to submit to support your claim)
Date:
Fiscal Year:
Claimant:
Amount:
PURPOSE:
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 allocation instruction.
FY 2013/2014
Omnitrans
1700 West Fifth Street
San Bernardino CA 92411
( ) 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
Attention:
Phone #:
mailto:
Authorizing Signature:
(Claimant's Chief Adminstrator or Financial Officer)
(Signature)
(Type Name & Title
Anna Rahtz
anna.rahtz@omnitrans.org
Claimant:
1. Project Name:
2. Project Name:
3. Project Name:
4. Project Name:
5. Project Name:
6. Project Name:
7. Project Name:
8. Project Name:
9. Project Name:
10. Project Name:
I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
Omnitrans
Inland Regional Center Bus Stop Imprvmts
Foothill Blvd and Campus Ave
Baseline Street and Victoria Ave
Riverside Dr and Archibald Ave
Vineyard Ave and Foothill Blvd
Foothill Blvd and Grove Ave
Boulder Ave and Highland Ave
Baseline Rd and Valeria Ave
Baker Ave and Fourth St
Euclid Ave and Fifth St
Total Project Expenditure
TDA Article 3 (SB 821)
* Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Total Project Expenditure
TDA Article 3 (SB 821)
Local Match
Signed:
Project
Budget
Cost
39200
31360
7840
2920
2336
584
20020
16016
4004
1859
1487
372
1859
1498
361
2359
1887
472
12527
10022
2505
1859
1487
372
2359
1887
472
13000
10400
2600
Date:
%
TDA
Budget
0
0
0
0
0
0
0
0
0
0
Project
Actual
Cost
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0