Art3_County_FY17_BikePed_WalkBikeSB_Inv08_APPROVED_210301_GK 351 N.Mountain View Ave,0303.San 9ernarmno.CA W415 I Pbone:909.38P.9146 Farr:909.387.6228
„„ei.SFr eurl r.uor
SAN BERNARDINO Public Health Derlarrn Porker
Dlreclor
COUNTY Admtntsh•ation Joining,
--
� Assistant Director
Mleraael A.9agatltra,M.D.
Ple-ants Officer
IN-KIND MATCH REPORT
Email In-Kind Report to: Date: 1/28/2021
neuvenkCdscag.ca.eov SCAG OWP H: 225.3564.1
Kana Sato-Nguyen In-Kind Match Report M: 12
Senior Budget&Grants Analyst Reporting Period: October I,2020-December 31,2020 Q4
Southern California Association of Govemments
900 Wilshire Blvd,17th Floor
Los Angeles,CA 90017 Project Title: San Bernardino County Safe Routes to School
Cast C'megones Hourly Hours AmouN Fringe Rine Fringe H)CRsge" /DC Amount
Direct Labor C[assi rcgtion s
Cent SRTS Project Coordinator $39.58 260.00 $10,29103 51.66% $5,316.34 15,449% $2,411.18 $18,018.55
Health Education Specialist 11 $0.00 51.66% Sam 15 449% S0.00 $0.00
PH Prog ain Manager $66,36 26.00 $1,725.35 51.66% $891.32 15.449% $404.25 $3,020.92
Public Hlth Prgm Coordinator $0.00 51.66% $0.00 15A49% $0.00 $0.00
Automated Svstcins Technician $27.47 0.75 $20.60 51.66% S10.64 15A49% 84.83 $36.07
Automated Systems Analyst l $0,00 51,66% 50.00 11149% S0.00 $0,00
Automated Systems Analyst l I S0-00 51 66% So "ol 19.449 $0()()1 S0 00
Subtotal- Direct Labe, 286.75 $12,036.98 $6,218301 S2,820.26 $21,075.54
Other Direct Costs/ODCsf
Printing Servicesv .,;5'K.. $5.50 $5.50
HS Admin Charges �/'''- S $0.00
County Counsel Charges - $0.00
CEHW Charges $0.00
Email Costs $273.N $273.14
Promotional Items $0.00
Tmvel Costs S0.00
Livescan/Background $0.00
Step Counters $0,00
Monitor Wool
Computer E ui ment $1,627271 1 $1,627.27
City of Rancho Cucamonga $0.00
City of Needles $0,00
City ofOntano $0.00
$0.00
$0.00
$0.06
$0.00
$0.00
Subtotal-ODCs: $1,905.91 $1,905.91
TOTAL for IN-RIND MATCH S13,942.89 $22,981.45
1,Paul Chapman,certify that this in-kind match report and the information attached is Ime and correct.I also certify that all eligible and required documentation is on
file for this report and that 1 am the person duly authorized to sign this certification on behalf of my agency.I further certify that our agency is not using any federal
funds to matcher funds.
1 f✓ Chief Financial Officer
Signature Title
Paul Chapman Z- I%- Z
Pant Name Date
•1f applicable,for credit of indirect costs for wok provided as in-kind contribution,a sub-recipient must submit an approved Indirect Con Allocation Plan(ICAP)or Indirect Cost Rate Proposal(ICRP)to
SCAG oo an annual basis for SCAG's review.If.sub-recipient has not received a negotiated indirect cest rate previously,then the sub-recipient may elect to charge a de minimis rate of 10%ofmodificd
toad direct costs(MTDC)-
r -
San Bernardino Associated Governments
Check List
Article 3 Grant Program
Claimant: County of San Bernardino Date: 1/20/2021
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.
A3 Claim County of San Bernardino SRTS ATP Cycle 3_5316BOD- FY2021 02
Check List
Page 1
San Bernardino Associated Governments
Claim Form
Article 3 Grant Program
Project Name: Walk and Bike SB Grant Allocation No: 1,18-0702-0754-01
Claimant: County of San Bernardino
Address: 340 N. Mountain View Avenue
San Bernardino,CA 92415-0010
Attention: Paul Chapman
Phone No: (909)387-6630
E-mail Address: Paul.Chapman@dph.sbcounty.gov
Amount Requested
for Reimbursement:';) 22, $1,45
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 Administrator or Financial Officer)
Date:
Signature
Paul Chapman, Chief Financial Officer
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.
�pllul�
A3 Claim County of San Bernardino SRTS ATP Cycle 3 5316BOD-FY2021 O2
Claim Form
Page 7
San Bernardino Associated Governments
Reimbursement Request
Article 3 Grant Program
Claimant: County of San Bernardino
Grant Information cote leted b SANBAG
Article 3
Total Project Award Percent
Project Name Cost Amount Article 3 Local Match ATP Funds
Walk and Bike SB $ 2,000,000 $ 320,000 16.0% $ 80,000 $ 1,600,000
Instructions: Please complete 1 through 4 below.
Amount
1)Article 3 Cost(amount being requested for
reimbursement) $ 22,981
2) Local Match/ATP Funds Cost
Total $ 22,981
Project Costs to Date(include amount requested above)
Local Match/ATP Funds
3)Article 3 $ 204,195 Remaining 1,600,000
4)Local Match/ATP Funds $ 80,000 Article 3 Balance Remaining 115,805
Total It 284,195 Total Amount Remaining 1,715,805
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: ' p Date: 2 — 12-Lt
A3 Claim County of San Bernardino SRTS ATP Cycle 3_5316BOD-FY2021 O2
Reimbursement Request
Page 1
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department Name mail Sum of Rate
MarkFriis Mark.Friis@dph.sbcounty.gov 67.359452
Grand Total 67.359452
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Your Shopping Cart CALCARD-0570 Page I of 3
Public Hearth J ! 3, y„
Cardholder: LAURA ROARK L(/ pl,(J (f
Period: 1 atz 1 zo
Subtotal(1) $1,522.56
Order Con li-JitLC
Estlmaled Shipping
$0.00
$104.]t m ecom_Lsbels:ce25alesTaa_fee lad
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• Customer agreement number:MNWNC-100/7157034003
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LAURA ROARK, SAN BERNARDINO COUNTY DPH
Customer Number:53DO16481346
172 WEST 3RD ST.DELIVER TO BASEMENT,SAN BERNARDINO CA 92415,US
Phone number(909)387-6214
LAURA,ROARK@OPH.SS000NTY.GOV
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Latitude 9510 1 $1.522.56 $1,522.56
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Catalog Number:84/rcrcl424883-5782141
Category Description Code SKU ID
Base Latitude 951Q BTX GTY827E [210-AVCNI I
Processor i Oth Generation Intel@ Core-IS10310 G8USGIV 1379-BDTVI 146
U(4 Core,6M cache,base L7GHz,up t
04.4GHz,vPm Capable)
Operating System Windows 10 Pro 64bit English.French, GF48XAl (619-AHKNI 11
Spanish
Office Productivity Software No Microsoft Office License Included-3 GC70FJV [658-BCSBI 1002
0 day Trial Offer Only
Base Options loth Gen Intel Core s-1031 OU vPro wit G4916ZL (338-SUTVI 149
h 16GB memory,Intel@ UHD Graphics
Systems Management Intel vPro Techno]ogys Advanced Man GN0591R 1631-ACMD] 49
agement Features
Memory 16GB,2133 MHz,LPDDR3,Integrated GEGR73S [370-AFKS) 3
Hard Drive M.2256GB Pete NVMe Class 35 Solid GHL6XKG 1400-BHRBI 8
State Drive
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Windows AutoPilot No Windows AutoPilot GYE02AP 1340-CKSZ1 291
Hardware Support Services 4 Years ProSupport Plus with Next Bus GVSH05J 1997-8367)1831- 29
areas Day Onshe Service 518111831-52071
1831-52081(831-
5209)(8 31-5 21 01
Subtotal(1):$1,522,56
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Subtotal(1) $1,522.56
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eceprom-Labels'.i,m-SaJmTm_fee-lab
$104.71
Total $1,627.27
Ulrraback,Ceteron,Celeron Inslde,Core Inside,Intel.Intel Logo,Intel Atom.Intel Atom Inside.Intel Care,inlet hall Intel Inside Logo,Intel vPm,fronlum.Ramum Inside,
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same day shlpmenl suh)ect 1D older size limitations,Dell Standard hurling methods and payment via credit card gat card or Dell Business Credit Notification will be
provided If then ere payment delays which could Impact shipping date.Electronics and accessories may ship separately.
Smart Selection.Limited quantities.Only available for older.placed by 5:59 Ran CT Mon.-Thera.Systems shipped the nest business day offer an order Is placed.Subject
to order approval,Software and...reactors not pall of the Canflgurellon WIII be shipped separately and may arrive offer your system.Please mile that Small selection
Configuration pricing cannot be combined with that pricing offers on discounts provided or agreed to by D.R.••Orders with Custom Factory Integration might require
additional processing time.
'Dell Business Credit:Offered to busies.customer¢by WebBank,Member FDIC,who determine$qualilisations for end terms of credit Texas,shipping and other Charges
are extra and very.Minimum monthly payments are The greeter of S15 or 3%of the new balance shown on the monthly billing statemml Dell and the Dell logo or.
trademark.of Dell Inc.
"Payment solutions provided and serviced by Dell Financial Services L.L.C,or its affiliate of designee('DFS')for qualified customers.Offers may not be avalleble or may
very in certain countries.Mete available,offers may be changed without narks and are subject to product availability,credit approval,execution of documentation
prayload by and acceptable to DFS,and may be subject to minimum transaction size.Offers rol available for personal,family or household use,Dell and the Dell toga are
lademafks of Dell Inc.Restrictions and additional requirements may apply to transactions with governmental of public pull,
'Subject to applicable law and regulations.
ALL ORDERS ARE SUBJECT TO APPROVAL AND ACCEPTANCE By DELL.Pricing,aysikblllly and other terms of offer may be wilhdrawn or changed without notice.Dell
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https://www.dell.com/premier/checkout/us/en/rcl 424883/ 10/6/2020
JV Upload Certification Document - Purchasing Printing Upload Page 1 of 8
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