Art3_Fontana_FY23_BikePed_Catawaba SRTS Sidewlaks_ClaimClaimant:
Please see below instructions and checkmark the items included in your submittal.
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City of Fontana
Claim Form (one-time submission) – required prior to, or along with, your first reimbursement request.
Authorizing Resolution (one-time submission) – required within SIX months of the project award by SBCTA Board or prior to requesting reimbursement of funds, whichever comes first. Resolution
should authorize the filing of the claim form, authorize the submission of reimbursement requests and designate the individuals authorized to certify project completion (Authorized
Agent). Sample language is available upon request.
Reimbursement Request Form (as needed) – this form is required every time a reimbursement is requested. Please note, progress payments are only eligible on awards over $200,000, the
requested amount must be a minimum of 20% of the award total, and the local match share percentage must be met regardless of reimbursement amount requested. Additionally, there is a
20% retention until project completion.
Backup Documentation (required with Reimbursement Request Form) – invoices, paychecks, purchase orders, etc. to support both the reimbursement and match amounts noted on the Reimbursement
Request Form. Please note, staff administration and/or contract project management expenses are NOT eligible match expenses. However, staff expenses may qualify for local match under
select circumstances. Please identify whether supporting documentation includes staff expenses under one of the following allowable conditions:
Backup Summary itemizing reimbursement request expenses.
Certification of Completion (completed projects only) – prior to filing the final request for reimbursement, written verification of project completion by the agency’s Authorized Agent
is required (see Authorizing resolution above). Sample language is available upon request.
Photos of Completed Project (completed projects only) – required when project is complete and should be attached to final reimbursement request.
Other (optional) – Claimants may attach additional information not included in this list to support the claim or reimbursement request. SBCTA may request additional information as necessary.
Award is for an ATP Safe Routes to School (SRTS) program project, not a SRTS infrastructure project.
Necessary staff time directly related to in-house completion of design, right-of-way acquisition, or construction including inspection and/or construction management.
Note: No travel costs or per diems allowed for staff time
Date:
Project Name:
Claimant:
Address:
Attention:
Phone No:
E-mail Address:
Award Amount
Purpose:
Note: this form only needs to be completed and submited with the full award amount once.
Authorizing Signature:
(Authorized Agent specified in Authorizing Resolution)
Signature
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.
Catawaba SRTS Sidewalk
City of Fontana
396348
Please check one purpose.
Article 3 Bicycle/Pedestrian Facilities, Public Utilities Code (PUC) 99233.3
Transit Stop Access Improvements, PUC 99233.3
Date:
Grant Allocation No:
L4-0702-0737
Claimant:
Complete fields in yellow below:
Section 1: Required for ALL Reimbursement Requests
Grant Information (completed by SBCTA)
Project Name
Catawaba SRTS Sidewalk
A: Invoice No.
B: Invoice Amount:
TDA Article 3
Local Match
ATP (if applicable)
Total
C: Scope Verification:
Check to verify expenses claimed are consistent with the approved scope below.
Installation of sidewalks, ADA-compliant driveways, and ADA-compliant curb ramps that close existing gaps along Catawaba Ave. as a "suggested route" for students attending Poplar Elem.
And Truman Middle Schools.
By signing below, I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
Signed:
City of Fontana
Previous
(if applicable)
0
(Authorized Agent specified in Authorizing Resolution)
Current
0
0
0
Cost to Date
0
0
0
0
Total Project Cost
792697
Balance
396348
396349
0
792697
Total Project Miles (if applicable)
Article 3 Award Amount
396348
.47
Section 2: Required for Progressive Reimbursements ONLY
A: Project Completion
B: Summary of Project Status
If either number turned red above, please provide a project schedule that demonstrates how the project will be completed on schedule within the budget. Provide attachments as needed.
Allocation #:
Percent
Article 3
0.499999369241968
Overall % Completed
Mileage Completed (if applicable)
Date:
L4-0702-0737
Local Match
396349
ATP Funds
(if applicable)
0
Share Completed:
0
Project Title:
Date
Total
Catawaba SRTS Sidewalk
Recipient's Name
Brief Description of Purchase
Amount
Include proof of payment with redacted account number.
0