Art3_LomaLinda_FY19_Transit_BartonCA_Claim-CLOSEDClaimant:
Please see below instructions and checkmark the items included in your submittal.
1.
2.
3.
4.
5.
6.
7.
City of Loma Linda
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).
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.
Reimbursement Request Form (as needed)
This form is required for every reimbursement requested.
Back-up Documentation (required with Reimbursement Request Form)
Please attach documentation supporting the amount requested (e.g., invoices, paychecks,
purchase orders, etc.)
Certified Copy of Minute Action (completed projects only)
Certified copy of minute action authorizing the filing of the final claim and verifying project completion.
Photos of Completed Project (completed projects only)
Other (optional)
Attach any other information you wish to submit to support your claim.
Date:
Project Name:
Claimant:
Address:
Attention:
Phone No:
E-mail Address:
Amount Requested for Reimbursement:
Purpose:
( )
(X)
Authorizing Signature:
(Claimant's Chief Adminstrator or Financial Officer)
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.
Accessibility Improvements at Barton and California ‐ EB and WB
City of Loma Linda
0
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:
L20-LL-05
Grant Information (completed by SANBAG)
Project Name
Accessibility Improvements at Barton and California ‐ EB and WB
Instructions: Please complete 1 through 4 below.
1) Article 3 Project Cost (amount being requested for reimbursement)
2) Local Match Project Cost
Total
Project Costs to Date (include amount requested above)
3) Article 3
4) Local Match
Total
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:
Claimant:
City of Loma Linda
Total Project Cost
39371.25
Amount
0
0
Article 3 Award Amount
31497
Percent Article 3
0.8
Local Match Amount Remaining
Article 3 Balance Remaining
Total Amount Remaining
Date:
Local Match Amount
7874.25
Percent Local Match
0.2
7874.25
31497
39371.25