Art3_Rancho_FY25_BikePed_HermosaAve_ClaimClaimant:
Please see below instructions and checkmark the items included in your submittal.
1.
2.
3.
4.
5.
6.
7.
8.
City of Rancho Cucamonga
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.
Hermosa Avenue Complete Streets Project
City of Rancho Cucamonga
537000
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:
L26-Art3-RCH-15
Claimant:
Complete fields in yellow below:
Section 1: Required for ALL Reimbursement Requests
Grant Information (completed by SBCTA)
Project Name
Hermosa Avenue Complete Streets Project
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.
Scope of Work: Remove a vehicle lane in both directions along Hermosa Ave from Banyan Ave to Foothill Blvd and install protected, Class IV bike lanes. Fill in 210 feet of sidewalk
gap on the west side of Hermosa to provide continuous pedestrian access. Improve comfort and safety for pedestrians by installing crossing enhancements at unprotected crossings at Mignonette
St and Monte Vista St.
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 Rancho Cucamonga
Previous
(if applicable)
0
0
0
0
(Authorized Agent specified in Authorizing Resolution)
Current
0
0
0
0
Cost to Date
0
0
0
0
Total Project Cost
912000
Balance
537000
375000
0
912000
Total Project Miles (if applicable)
Article 3 Award Amount
537000
3
Section 2: Required for Progressive Reimbursements ONLY
A: Project Completion
B: Summary of Project Status
3) 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
0.588815789473684
1) Overall % Completed
2) Mileage Completed (if applicable)
Date:
L26-Art3-RCH-15
Local Match
375000
Percent
Local Match
0.411184210526316
Share Completed:
0
Project Title:
Date
Total
Hermosa Avenue Complete Streets Project
Recipient's Name
Brief Description of Purchase
Amount
Include proof of payment with redacted account number.
0