Art3_County_FY17_BikePed_WalkBikeSB_Inv07_APPROVED_201023_GK 351 North Mt.View Avenue,San Bernardino,GA 92514 Phone_909 387 9146 1 Fax 909,387.6226
www-Wotrtlll
Public Health Corwin Porter
SAN BERNARDINO Direclor
C0LTNTY Administration Josh Dugas
Assislarit Director
Erin Gustafson,M.D.,MPH
Interim Health Officer
IN-KIND MATCH REPORT
Frail In-bind Report to: pate: 10/20/2020
ngtivenk(h)scae.ca.p�ov SCAG OWP At:225.3564.1
Kana Sato-Nguyen In-Kind Match Report 0: 11
Senior Budget&Grants Analyst Reporting Period: July I,2020-September 30,2020 Q3
Southern California Association of Governments
900 Wilshire Blvd, 17th Floor
l Angeles,CA 90017 Project"ride: San Bernardino County Safe Routes to School
Cosr Categoric., Hourly Hours Amount Fringe Rote Fringe 1DC Rate* CDC Amount
Direct Labor Ciassi leation s:
Cant SRTS Proieca Coordinator S39.58 186,00 S7.362 09 5 1.66% S3.803.25 t5.449% $1,724.9.1 $12.890,27
1fealth Education Specialist 1] $0.00 51.66% $0.00 15 449% S0,00 $0.00
PH Program Manager $64.74 32.00 S2.U71.79 51.66% S1,070.29 15.449% $48542 $3,627.50
Public Hlth Pl Coordinator $0.001 51.66% $o.00 15.449% $0.00 $0.00
Automated S stems Technician $26.14 250 S65.35 51.66% $33,76 15.4491/. $15.31 $1 I4.42
Automated Systems Analyst I $0.00 51,66% $0.00 HA491/0 $0.00 $0.00
Automated Systems Analyst 1 $0.00 51.66% $0 00 15.449% $0.00 $0.00
Subtotal- Direct Labor 220.50 $9,499.23 $4,907.30 52,225.66 $16,632.1➢
Other Direct Costs 0QC.v
Printing Semites $0.00
HS Admin CIml $0,00
Cmrnt Counsel Charges $0.00
FL 'A Charues $0.00
Email Costs SN-'.96 $82.96
Promotional items $0.00
TraNd Costs $0.00
Livescan/Background $0.00
Step Counters $0.00
Monitor
$0.00
Computer Equipment $0.00
City of Rancho Cucamonga Sl
City of Needles $8,715,64
City of Onrario S,,gun u0 $3,300.00
$0,00
$0.00
$0.00
S0.00
Subtotal-ODCs: $12,098.60 S 3 2,098.6t1
TOTAL for IN-KIND;MATCH $21,597.83 S28,730.79
1,Paul Chapman,certify that this in-kind match report and the information attached is true and correct.I also certifythat all eligible and required documentation is on
g q
file for this report and that I 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 t�expe e funds.
Imerim Chief Financial Officer
Siptature Title 9
Paul Chapman l Q Z 1-Z-0
Print Name Date
'Ifapplicable,for credit of indirect costs for work provided as in-kind contribution.a sub-recipient must submit an approved Indirect Cost Allocation Plan(ICAP)or Indirect Cost Rate Proposal([CRP)to
SCAG on an annual basis for SC.AG's review.If a sub recipient has not received a negotiated indirect cost rate previously,then the sub-recipient may elect to charge a de minimis rate of l l of modified
total direct costs(MTDC) All
Bill OF SUPERVISORS
'r: rrr JANtcF.RtyrHeRl DAWN Ill Cult r HAGMAN JOSIF.l I Leonard X Hernandez
Fint District Second tclaerti-mulCl
San Bernardino Associated Governments
Check List
Article 3 Grant Program
Claimant: County of San Bernardino Date: 10/20/2020
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 Bemardino SRTS ATP Cycle 3_5316BOD-FY2021 Q1
Check List
Page 1
San Bernardino Associated Governments
Claim Form
Article 3 Grant Program
Project Name: Walk and Bike SB Grant Allocation No: L18-0702-0754-01
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: $ 28,730.79
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)
Date: —L I-ZD
Signature
Paul Chapman, Interim Chief Financial Officer
Type Name Bc 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. I
A3 Claim County of San Bernardino SRTS ATP Cycle 3_5316BOD-FY2021 Oi
Claim Form Page 1
San Bernardino Associated Governments
Reimbursement Request
Article 3 Grant Program
Claimant: County of San Bernardino
Grant Information (completed by 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
l)Article 3 Cost(amount being requested for
reimbursement) $ 28,731
2) Local Match/ATP Funds Cost
Total $ 28,731
Project Costs to Date(include amount requested above)
Local Match/ATP Funds
3)Article 3 $ 181,214 Remainin 1,60Q 000
4)Local Match/ATP Funds $ 80,000 Article 3 Balance Remaining 138,786
Total $ 261.214 1 Total Amount Remainingl1,738,786
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: I y Date: ID-7I-7
QV 1012 2,0
A3 Claim County of San Bernardino SRTS ATP Cycle 3_5316BOD-FY2021 01
Reimbursement Request
Page 1
EMACS Salaries
LID Program Id 2903
Prod Time y
AugustSum of Sum LID Amount Pay Period End2 Pay Period End
Descr Name July -.
Fnis,Mark 2,341.14 3,751.80 5,072.40 11,165.34
Rigsby,Scott 1,276.47 589.14 1,276.47 3,142.08
Almanza Theresa 99.11 99.11
Grand Total 3,617.61 4,440.05 6,348.87 14,406.53
Salary 9,499.23
Benefits 51.66% 4 907.30
14,406.53
Indirect 15.449% 2,225.66
LID Program Id 2903 Salary& Indirect 16,632.19
Prod Time y
PeriodSurn of Sum Hours -
Pay End2 Pay Period End
All 20
'Descr Name Sept 20 Grand Total
Friis,Mark _ 39.00 62.50 84.50 186.00
Rigsby,Scott 13.00 6.00 13.00 32.00
Almanza Theresa 2.50 2.50
Grand Total 52.00 71.00 97.50 220.50
Hours Rate Salary Benefits Total Indirect Total Amount
186.00 39.58 7,362.09 3,803.25 11,165.34 1,724.93 12,890.27
32.00 64.74 2,071.79 1,070.29 3,142.08 485.42 3,627.50
2.50 26.14 65.35 33.76 99.11 15.31 114.42
9,499.23 4,907.30 14,406.53 2,225.66 ✓ 16,632.19
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City of Needles INVOICE
Atten: Cheryl Sallis
917 Third Street _
Needles, CA 92363 voice:Date.herin
: 060420SRTS \1
760-326-2113 ext H 5 Invoice e 4, 2020
Billed To;
Dept of Public Health Per Patty's direction,emailed to:
Atten: Patty Castillo,Office Asst N1urk,b`riis(q dlth-shvf,.. tv< 11
(Healthy Communities)
1?sasiillors%z9,pl�.yipcxae�st9 a�t
Order Dumber Tn
"`—
Terms
ys
Date Description of ServicesRate
Amount
County Contract No. M-t057-0003 with De
Public Health to provide Sate Routes to Sch
Program Services --Enforcement of Traffic
Participating Schools
San Bernardino County Sheriff's Dept SRTS
enforcement for the 2019-2020 fiscal year(pschool closures on March 16, 2020 due to
Covid-19) --see attached
109 horns @ $79.96/hour=$8,715.64 $8,715.64
Total Contract=$21,600
Balance remaining carried into 2020.21 =$12,884.36
We appreciate your business! Total $8,715.64
EVuaace\Sale Routes to Senool invoice-traffic-enforcement-2019-20 ty.Axr✓elw
PO ��oo►sei3'}
*� Invoice:
INVOICE n146
x 7 Invoice Date: June 9,2020
Page: 1 of 1
Please Remh To:
City of Ontario Customer No: 0000019452
Revenue Services Payment Terms: Immediate
303 E.B-Street Due Date: June 9,2020
Ontario,CA 91764
AU unpaid balances after 30 days from invoice date are subject to a late
charge of 100%and a 0.5%penalty per month thereafter,
Department of Public Health
Attn:Patty Castillo, Office Assistant AMOUNT DUE: 3,300.00
172 West 3rd St.,6th Floor
San Bernardino CA 92415-0010
PLEASE DO NOT SEND THIS PAYMENT WITH YOUR ONTARIO UTILITY PAYMENT
PLEASE ENCLOSE THIS STUB WITH YOUR REMIT`rANCE--
For billing questions,Please call:City of Ontario 909-395-2342 Invoice: a 77146
Line Description
Net Amount
1 County Contract M-1057-002
FY2079-20 Safe Routes to Schools Grant(County Contract M-1057-002) 3300.00
Reimbursement for expenses related to gram personnel overtime.
Claim 1-Final Claim
AMOUNT DUE: 3,300.00
Okey to
f/pay