Art3_Fontana_FY17_BikePed_ABMillerSRTS_Claim_CLOSEDClaimant: City of Fontana Date:
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.
Project Name: Bike Ped Rte Maint AB Miller HS Grant Allocation No: L18-0702-0737-01
Claimant: City of Fontana
Address:
Attention:
Phone No:
E-mail Address:
Amount Requested for Reimbursement:
0
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:
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.
Claimant: City of Fontana
Grant Information (completed by SANBAG)
Project Name Total Project Cost Article 3 Award Amount Percent Article 3 Local Match Amount Percent Local Match
Bike & Ped Route Maint AB Miller HS 162000 50000 0.3086 112000 0.6914
Instructions: Please complete 1 through 4 below.
Amount
1) Article 3 Project Cost (amount being requested for reimbursement)
2) Local Match Project Cost
Total 0
Project Costs to Date (include amount requested above)
3) Article 3 Local Match Amount Remaining 112000
4) Local Match Article 3 Balance Remaining 50000
Total 0 Total Amount Remaining 162000
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: Date: