Art3_VVTA_FY21_Transit_HesperiaRd_ClaimClaimant:
Please see below instructions and checkmark the items included in your submittal.
1.
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Victor Valley Transit Authority
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.
Hesperia Rd Between Chalan Rd and Sunset Drive
Victor Valley Transit Authority
51722.41
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:
L22-0702-0751-02
Claimant:
Grant Information (completed by SBCTA)
Project Name
Hesperia Rd Between Chalan Rd and Sunset Drive
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:
Victor Valley Transit Authority
Total Project Cost
64651.01
Amount
0
0
Article 3 Award Amount
51722.41
Field will change to red
if local share is not met
Allocation #:
Percent Article 3
0.800024779195252
Article 3 Balance Remaining
Local Match
ATP Funds (if applicable)
Total Amount Remaining
Date:
L22-0702-0751-02
Local Match
12928.6
ATP Funds
51722.41
12928.6
0
64651.01