Art3_Omnitrans_FY13_Transit_46stops_Status_170328Claimant:
The Check-List below are items that must be included with your submission for reimbursement
S-1407-14
Kendall at University
Del Rosa at Date - CLOSED
E St at 14th - CLOSED
E St at 18th
9th at Medical Center
E St at 16th
Sultana at Transit - CLOSED
Campus at Holt - CLOSED
Waterman at 5th
Sierra at 16th
Kendall at H St
48th at 4th WB - CLOSED
Tippecanoe at San Bernardino
San Bernardino at Live Oak
9th at Western
Sierra at 16th
Vineyard at 7th
Sierra at 30th
1.
2.
3.
4.
5.
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)
O at 9th
San Bernardino at Hemlock
Merrill at Beech WB
Kendall at 48th
San Bernardino at Indigo
5th at Benson - CLOSED
Sierra at 19th
C at Pennsylvania
C at Pennsylvania WB
Euclid Ave at 4th
Baseline at Meridian EB
6th St at Grove
Euclid at Belmont
Merrill at Beech EB
Jurupa at Etiwanda
San Bernardino at Sycamore
Inland Empire at Mercedes
San Bernardino at Redwood
Date:
Euclid at Riverside
Milliken at Santa Ana - CLOSED
Baseline at Pepper EB
Milliken at Jurupa
San Bernardino at Eucalyptus
Wildrose at Woodpine SB - CLOSED
Riverside at Senior Way SB - CLOSED
Riverside at James SB
Milliken at Toyota - CLOSED
C St at 2nd
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:
I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
Omnitrans
Article 3 Transit Stop Access S-1407-14
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
161879
129503
32376
Date:
%
TDA
Budget
0.8
0
0
0
Project
Actual
Cost
0
0
0
0
0
0
0
0
0
0
0
0