Art3_Rialto_FY25_BikePed_SRTS_ClaimSigned San Bernardino County Transportation Authority
Claim Form
Article 3 Grant Program
Project Name: Rialto Safe Routes to School Improvements Project Grant Allocation No: L26-Art3-RIA-16
Claimant: City of Rialto
Address: 150 S.Palm Avenue
Rialto,CA 92376
Attention: Yazdan Emrani,P.E.
Phone No: 909-421-7229
E-mail Address: yemrani@rialtoca.gov
Award Amount $ ixo,QOO.t)0
Purpose: Please check one purpose.
121 Article 3 Bicycle/Pedestrian Facilities,Public Utilities Code(PUQ 99233.3
❑ Transit Stop Access Improvements,PUC 99233.3
Note:this form only needs to be completed and submited with the full award amount once.
Authorizing Signature:
(Authorized Agent specified in Authorizing Resolution)
Date:
Signature
Yazdan Emrani,P.E.,Public Works Director
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.
Art3_Rialto_FY25_Bi kePed_S RTS_Cla i m
Claim Form Page 1
Claimant:',City of Rialto Date: 3/30/2026
Please see below instructions and checkmark the items included in your submittal.
1. Claim Form (one-time submission)—required prior to,or along with,your first reimbursement
request.
2. 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.
❑ 3. 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.
4. 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:
❑ 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
❑ 5. Backup Summary itemizing reimbursement request expenses.
❑ 6. 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.
❑ 7. Photos of Completed Project(completed projects only)—required when project is complete
and should be attached to final reimbursement request.
❑ 8. 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