Art3_County_FY21_BikePed_BloomingtonSchools_ClaimSigned Claimant: County of San Bernardino- DPW Date: 4/28/2022
Please see below instructions and checkmark the items included in your submittal.
El 1. Claim Form (one-time submission)—required prior to, or along with,your first reimbursement
request.
0 2. 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.
❑ 3. 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.
❑ 4. 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:
❑ 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
❑ 5. 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.
❑ 6. Photos Of Completed Project(completed projects only)—required when project is complete
and should be attached to final reimbursement request.
❑ 7. 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.
San Bernardino Associated Governments
Claim Form
Article 3 Grant Program
Project Name: Bloomington Area Schools Project Grant Allocation No: L22-0702-0754-00
Claimant: County of San Bernardino-DPW
Address: 825 East Third Street
San Bernardino,CA 92415
Attention: Robert Lopez
Phone No: (909)387-8180
E-mail Address: robert.lopez@dpw.sbcounty.gov
Award Amount $ 85,500.00
Purpose: Please check one purpose.
0 Article 3 Bicycle/Pedestrian Facilities,Public Utilities Code(PUC)99233.3
❑ Transit Stop Access Improvements,PUC99233.3
Authorizing Signature:
(Authorized Agent t specified in Authorizing Resolution)
( : Q�
Date. 04 28 2022
Signature
Aimee Westrom,Chief Financial Officer
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.
Art3_County_FY21_BikePed_BloomingtonSchools_Claim(2)
Claim Form Page 1