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Art3_Rialto_FY21_BikePed_MerrillSRTS_ClaimClaimant: Please see below instructions and checkmark the items included in your submittal. 1. 2. 3. 4. 5. 6. 7. City of Rialto 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: 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. Merrill SRTS City of Rialto 639404.61 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: L22-0702-0747-01 Claimant: Grant Information (completed by SBCTA) Project Name Merrill SRTS Instructions: Please complete 1 through 5 below. 1) Article 3 Cost (amount being requested for reimbursement) 2) Local Match/ATP Funds Cost Total Project Costs to Date (include amount requested above) 3) Article 3 4) Local Match 5) ATP (if applicable) Total I certify that the information on this Financial Reporting form is true and accurate to the best of my knowledge. (Authorized Agent specified in Authorizing Resolution) Signed: City of Rialto Total Project Cost 1454969.22 Amount 0 0 Article 3 Award Amount 639404.61 Field will change to red if local share is not met Allocation #: Percent Article 3 0.4394626368797 Article 3 Balance Remaining Local Match ATP Funds (if applicable) Total Amount Remaining Date: L22-0702-0747-01 Local Match 815564.61 ATP Funds 639404.61 815564.61 0 1454969.22