Art3_County_FY17_BikePed_WalkBikeSB_Inv02 San Bernardino Associated Governments
Check List
Article 3 Grant Program
Claimant: County of San Bernardino Date: 7/30/2019
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-Q4
Check List
Page 1
San Bernardino Associated Governments
Claim Form
Article 3 Grant Program
Project Name: Walk and Bike SB Grant Allocation No: L]8-0702-0754-01
Claimant: County of San Bernardino
Address: 340 N.Mountain View Avenue
San Bernardino,CA 92415-0010
Attention: Joshua Dugas
Phone No: (909)387-6222
E-mail Address: Joshua.Dugas@dph.sbcounty.gov
Amount Requested
for Reimbursement: $ 27,624.33
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)
�, _xt, Date: 7!3 1 Al
Signature
Paul Chapman,Administrative 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.
A3 Claim County of San Bernardino SRTS ATP Cycle 3_5316BOD-O2
Claim Form Page 1
San Bernardino Associated Governments
Reimbursement Request
Article 3 Grant Program
Claimant: County of San Bernardino
Grant Information com leted bv 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
Instructions: Please complete 1 through 4 below.
Amount
1)Article 3 Cost(amount being requested for
reimbursement) $ 27,624
2) Local Match/ATP Funds Cost
Total $ 27,624
Project Costs to Date(include amount requested above)
Local Match/ATP Funds
3)Article 3 $ 49,903 Remaining1,600.000
4)Local Match/ATP Funds $ 80,000 Article 3 Balance Remaining270,097
Total $ 129,903 Total Amount Remaining 1,870,097
V/ -,13'�lY
1 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: ' �� Date: a 1
A3 Claim County of San Bernardino SRTS ATP Cycle 3_5316BOD-O2
Reimbursement Request Page 1
EMACS Salaries
LD Program Id 2903
Prod Time y
PeriodiSum of Sum LD Amount Pay End2 Pay Period .
Descr Name Apr May Jun -
Total
Q4 LD factor Total
Friis,Mark 4,261.66 3,673 85 3,428.92 11,364.43 11,364.43 1,313.22 12,677.65
Riqsby Scott 742.64 1,032.78 _ 856.43 2,631.85 2,631.85 309.28 2,941.13
Aceves Alex 28.29 28.29 28.29 0.71 29.00
Grand Total 5,032.59 4,706.63 4,25 35 1Z024.57 14,024.57 1.623.21 15,647.78
Salary 10,547.17
Benefits 48.36% 5,100.61
15,647.78
Indirect 16.33% 2,555.28
LD Program Id 2903 Salary&Indirect 18,203.06
Prod Time y
PeriodSLIM of Sum Hours Pay Period End2 Pay
Descr Name --Apr May Jun Grand Total
I-nis,Mark 87.00 75.00 70.00 232.00
Rigsby Scott 8.00 11.00 9.00 28.00
0.75 0.75
Grand Total 95.75 86.00 79.00 260.75
Hours Rate Salary Benefits Total Indirect Total Amount
232.00 36.83 8,545.20 4,132.45 12,677.65 2,070.26 14,747.91
28.00 70.80 1,982.43 958.70 2,941.13 480.29 3,421.42
0.75 26.07 19.55 9.45 29.00 4.73 33.73 -
10,547.18 5,100.60 15,647.78 2,556.28 18,203.06
county of San Bernardino - BNACs
LA
Report ID: SBLDO30 LABOR DISTRIBUTION - MAJOR PROGRAM BY PROGRAM BY JODCODB Page No. 165
Pay Period End: 06/21/19 Run ID: U14 Run Date 07/17/19
LWROUP : PHLTH - Public Health NJ Program: 29 Run Time 18:26:22
WORK - NON-WORK
PROGRAM SOBCO
Y-T-O Y-T-D Y-T-D Y-T-O
UNITS AMOUNT UNITS AMOUNT UNITS AMOUNT UNITS AMOUNT
2903 Safe Route. to School 01679 Automated Systems Technician 1 $28
16378 PH Program Managet 3 $285 133 $12,344
28730 Cent SRTS Project Coordinator 48 $2,351 11070 $52,413 SO $350
PROGRAM 0903) TOTALS 51 $2,637 1,204 $69,786 30 $350
�( 2 5o5S 76 Lo ` =-�`
Repo[[ ID: SELDOSO County of San Bernardino - EMACS
LABOR DISTRIBUTION - MAJOR PROGRAM BY PROGRAM BY .IOBCODE Page No. 144
LW'ROOP 2HLTR - public Health Pay Period End: 03/29/19 Run ID: UOS Run Date 04/06/19
MJ P[og[am: 29 Run Time 34:29:40
- WORK NON-WORK
PROGRAM Y-T-O Y-T-D
SOBCD UNITS AMOUNT UNITS AMOUNT UNITS AMOUNT UNITS AMOUNT
2903 Safe Routes to School 16378 PH Program Manager 4 $311 105 $9,712
28]3] Cont SRTS Project Coordinat0[ 50 $2,449 838 $91,049 5 $175
PROGRAM (2903) TOTALS 54 $2,921 943 $50,761 5 $175
Services&Supplies
Val...
Description of Funded Program (Multiple Items) 50 A
Budget Period 2019
Fund 3000 5�1 Description of Funded Program 2903SAFE ROUTES TO SCHOOL
Value Type (Multiple Items) F5- -- Budget Period (All,
Apr May JunSum of Amount to be checked against payment bud Column Labels 60 Value Type (Multiple home)
Correct claim amount SILTS 1/2019-3/2019 0,25 0.25 52
SRTS 1120193/2019 (22,279.00) (22,279.00) PHL CAL CARD JUNE 2019 _ 207,38 207.38 '
PHL Grand Total 20Z38 207,18 CAL CARDS APRIL2019 3,188.]] 3,188.77 Descrintio...
Dec 2018 PHL P.Castillo 1530 Used Tax 112.00 112.00 2900-COM...
1530 P.Castillo Of Apr 2019 195.20 195.20
1530 P.Castillo Of Noy 2018 56.00 56.00 2901-HEAL... f
2902-CALIF...
PHL CAL CARD MARCH 2O19 716.00 716.00 S '�-I
3249&SRTS PROGRAM 777.69 77769 2904-NEW ...
2905-REEN...
APRIL LIVESCAN 26.00 26.00 2910-STATI...
April 2019 Fingerprinting 32.00 32.00 2930-COM...
Mar 2019 Enrolls 11LS9 111.S9 NOT RELE...
Apr 2019 Emails 114.48 114.48
May 2019 Emails 112.30 112.30
2902 -GY 1...
HIS ADMIN PP07-11/19 986.83 986.83 2903-GY171...
HS ADMIN PP01-06/19 936.66 936.66 2905-GY171...
COUNTY COUNSEL MARCH 306.00 306.00 (blank)
HS ADMIN PP07-11/19 187.50 187.50
HS ADMIN PP01-06/19 177.97 177.97
Grand Total 1,911.28 3,361.25 (19,514.29) (14,241.76)
Query 1,911.28 3,361.25 (19,514.29) (14,241.76)
Less Revenue 22,278.75 22,278.75
June Manual Adj-Email 109.35 ' 209.35
June Manual Adj-Monitor 1,067.55 ' 1,067.55
June Cal-Card Posted FY19-20 207.38 ' 207.38
Less:Printing service applied to in-kind match
1,911.28 3,361.25 4,148.74 9,421.27
Category Grant In-Kind Match Total
S&B 15,M7.78 - 15,647.78 '
S&S 9,421.27 - 9p21.27 '
Indirect 2,555.28 2,SS5.28
27,624.33 27,624.33
18-19 Year End Adjustments Pivot - Manual Adj
Sum of Amount
Cost Center GL ACCOUNT Internal Order Description REFERENCE Total
9300291000 52412410 1007347 June 2019 Emails MA1819004 109.35
52002116 1007347 Dell OptiPlex 7460 AIO MA1819011 1,067.55
9300291000 Total 1,176.90
Grand Total 1,176.90
7/30/2019 11:23 AM
View Invoice 1 48HourPrint P ge 1 of 1
L VL46 I-19 �C.
CALCARD-1530 )00 Haskell Ave,Van Nuys,CA 91406
48Hour COm Public Health Toll Free:BOD-844-0599
Cardholder:Patricia Castillo Mon-Fri(9am-8pm EST)
Period: (0 h r( IIcl
Invoice for Order# 5836561 I` 1 Bill to: Patricia Castillo
mark Friis
Order Date:06/5/2019 351 N. Mt.View Ave,San Bernardino,CA,ID 4837199
P.O.#. Email:mark.fiis@dph.sbcounty.gov I Phone:(909)800-4322
Product Details Delivery a Destination Quantity Prim
rTEla 08934244 Delhrory
Pmdua Retractable Banners 1 Day Transit
Graphic Size:33.5 x 79
Display Options:Stand«1 Banner(Single Sa San Bng Address
emerNno CCU"SRTS
Skied)
Frame Color:Sher ATTN:Patrlda Castillo 2 $422.45
Printed Side:Front Only 172 weal 3re Strata,Bth Floor
Msdamd:13 oz Poly Flim San Bernardino,CA 92415
Printing Turnaround:4 Business Days Phone:(909)367-6604
Shipping a Handling:823.04
Payment Information Subtotal $422.45
Credit Card
account 33.47 04
Payment Data:0 6/0512 01Shippingl ,V////
Shipping a handling $2 523.oa
Sales Tax $15.36
Order Total $207.38
Paid $207.38
Balance Due $0.00
AN orders are sub)eot to tee Terms 8 Conditions on 481,iourPnnt.com.For details,please visit htMa 6Wmv.48houmr1nLwnuterm -o"4e html
https://www.48hourprint.com/portal/view-invoice/5836561 6/5/2019