Art3_Fontana_FY17_BikePed_AlderSRTS_Inv2_APPROVED_200316San Bernardino Associated Governments
Claim Form
Article 3 Grant Program
Project Name: Alder Middle School SRTS Project Grant Allocation No: LI8-0702-0737-00
Claimant: City of Fontana
Address: 8353 Sierra Avenue
Fontana, CA 92335-3528
Attention: Margo Arispuro
Phone No: 909-350-6782
E-mail Address: marispuro@fontana.org
Amount Requested
for Reimbursement: $ 10.542.87 -----------
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
Jeff Kim, Engineering Manager
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.
Billing 2 FY 1718 A3 Claim City of Fontana Alder Middle School SRTS Project.xlsx
Claim Form Page 1
San Bernardino Associated Governments
Check List
Article 3 Grant Program
Copy of Art3_Fontana_FY17_BikePed_ABMiller_Claim (2)
Check List Page 1
City of Fontana Date:3/16/2020
Please see below instructions and checkmark the items included in your submittal.
X 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).
X 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.
X 3.Reimbursement Request Form (as needed)
This form is required for every reimbursement requested.
X 4.Back-up Documentation (required with Reimbursement Request Form)
Please attach documentation supporting the amount requested (e.g., invoices, paychecks,
purchase orders, etc.)
N/A 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.
N/A 6.Photos of Completed Project (completed projects only)
N/A 7.Other (optional)
Attach any other information you wish to submit to support your claim.
Claimant: