Art3_AppleValley_FY21_BikePed_BearValleyBridge_ClaimClaimant:
Please see below instructions and checkmark the items included in your submittal.
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Town of Apple Valley
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, progressive payments are only eligible on awards over $200,000 and
local match share percentage must be met regardless of reimbursement amount requested.
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:
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.
Bear Valley Rd Bridge Connector
Town of Apple Valley
232300
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:
L22-0702-0731-00
Claimant:
Section I: Required for all Reimbursement Requests (1-5)
Grant Information (completed by SBCTA)
Project Name
Bear Valley Rd Bridge Connector
A: Current Request for Reimbursement
TDA Article 3 Reimbursement Amount Requested
Local Match
ATP Funds Utilized
1) Total Spent*
*Shares will be automatically cacluated based on non-rounded formula.
B: Project Costs to Date (include amount requested above)
2) TDA Article 3
3) Local Match
4) ATP (if applicable)
Total
C: Balance Remaining
TDA Article 3
Local Match
ATP Funds (if applicable)
Total
5) Check to verify expenses claimed are consistent with the approved scope.
Construct a multi-use path connecting a Class I bike path from Appley Valley to Victor Valley College.
By signing below, I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge.
Signed:
Town of Apple Valley
(Authorized Agent specified in Authorizing Resolution)
Total Project Cost
464600
0
0
0
0
232300
232300
0
464600
Total Project Miles (if applicable)
Article 3 Award Amount
232300
0
0
0
0
1
1
0
1
.32
Section II: Required for Progressive Reimbursements ONLY (1-3)
A: Project Completion (turns red if % completed is significantly less than invoice)
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
0.5
1) Overall % Completed
2) Mileage Completed (if applicable)
Date:
L22-0702-0731-00
Local Match
232300
ATP Funds
(if applicable)
0
Share Completed:
0
Project Title:
Date
Total
Bear Valley Rd Bridge Connector
Recipient's Name
Brief Description of Purchase
Amount
(include proof of payment)
0